Healthcare Provider Details

I. General information

NPI: 1225692734
Provider Name (Legal Business Name): TARA KOWALIK BSN, RN, RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2019
Last Update Date: 04/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2451 BASELINE RD
GRAND ISLAND NY
14072-1657
US

IV. Provider business mailing address

2451 BASELINE RD
GRAND ISLAND NY
14072-1657
US

V. Phone/Fax

Practice location:
  • Phone: 716-773-8870
  • Fax: 716-773-8985
Mailing address:
  • Phone: 716-773-8870
  • Fax: 716-773-8985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number526844-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: