Healthcare Provider Details

I. General information

NPI: 1740286608
Provider Name (Legal Business Name): KATHLEEN HENECKE PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 07/13/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 MAIN ST STE 302
CORTLAND NY
13045-6615
US

IV. Provider business mailing address

RD#1 CEMETARY ROAD
FABIUS NY
13063
US

V. Phone/Fax

Practice location:
  • Phone: 607-753-3798
  • Fax: 607-753-6677
Mailing address:
  • Phone: 315-677-9779
  • Fax: 607-753-6677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberF380804-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number5323055
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: