Healthcare Provider Details

I. General information

NPI: 1902182520
Provider Name (Legal Business Name): KELLIE ANNE KASCHAK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2011
Last Update Date: 10/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17400 NY HIGHWAY 22
CHERRY PLAIN NY
12040
US

IV. Provider business mailing address

PO BOX 259
BERLIN NY
12022-0259
US

V. Phone/Fax

Practice location:
  • Phone: 518-658-2515
  • Fax: 518-658-0483
Mailing address:
  • Phone: 518-658-2515
  • Fax: 518-658-0483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number350322
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: