Healthcare Provider Details

I. General information

NPI: 1265165617
Provider Name (Legal Business Name): KAYLA PETUTIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2022
Last Update Date: 07/05/2022
Certification Date: 07/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 LAUREL AVE
CORNWALL NY
12518-1403
US

IV. Provider business mailing address

70 DUBOIS ST
NEWBURGH NY
12550-4851
US

V. Phone/Fax

Practice location:
  • Phone: 845-458-4267
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number04859901
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: