Healthcare Provider Details

I. General information

NPI: 1659881555
Provider Name (Legal Business Name): KIM LETOURNEAU RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2017
Last Update Date: 10/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 ROUTE 276
CHAMPLAIN NY
12919
US

IV. Provider business mailing address

12 TRAHAN DR
ROUSES POINT NY
12979-1512
US

V. Phone/Fax

Practice location:
  • Phone: 518-298-8638
  • Fax: 518-298-2873
Mailing address:
  • Phone: 518-297-3344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number476565-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: