Healthcare Provider Details

I. General information

NPI: 1760163612
Provider Name (Legal Business Name): KAITLYN TAYLOR BARTNIKOWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KAITLYN TAYLOR BAUDILLE

II. Dates (important events)

Enumeration Date: 07/25/2023
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5645 MAIN ST
FLUSHING NY
11355-5045
US

IV. Provider business mailing address

347 WELLINGTON RD
MINEOLA NY
11501-1437
US

V. Phone/Fax

Practice location:
  • Phone: 631-338-4732
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number031017
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: