Healthcare Provider Details

I. General information

NPI: 1083429401
Provider Name (Legal Business Name): KATELYN MCKINLEY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2025
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 W MAIN ST
CANTON NY
13617-1358
US

IV. Provider business mailing address

39 W MAIN ST
CANTON NY
13617-1358
US

V. Phone/Fax

Practice location:
  • Phone: 315-379-4700
  • Fax: 315-713-6512
Mailing address:
  • Phone: 315-379-4700
  • Fax: 315-713-6512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number355341
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: