Healthcare Provider Details

I. General information

NPI: 1295570034
Provider Name (Legal Business Name): KMC NURSE PRACTITIONER IN ADULT HEALTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2024
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9097 MAIN ST
CLARENCE NY
14031-1965
US

IV. Provider business mailing address

9097 MAIN ST
CLARENCE NY
14031-1965
US

V. Phone/Fax

Practice location:
  • Phone: 716-759-4938
  • Fax: 716-759-4939
Mailing address:
  • Phone: 716-759-4938
  • Fax: 716-759-4939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KYM CANNIZZARO
Title or Position: OWNER/NP
Credential:
Phone: 716-759-4938