Healthcare Provider Details

I. General information

NPI: 1992114359
Provider Name (Legal Business Name): KELLY ANNE BAXTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2014
Last Update Date: 10/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 COUNTY OFFICE BLG 6
CAIRO NY
12413
US

IV. Provider business mailing address

905 COUNTY OFFICE BLDG 6
CAIRO NY
12413
US

V. Phone/Fax

Practice location:
  • Phone: 518-622-9163
  • Fax: 518-622-8592
Mailing address:
  • Phone: 518-622-9163
  • Fax: 518-622-8592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF401758-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: