Healthcare Provider Details

I. General information

NPI: 1487439667
Provider Name (Legal Business Name): EMILY ROSE REGAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8326 MAIN ST
INTERLAKEN NY
14847-9789
US

IV. Provider business mailing address

82 N PINE AVE
ALBANY NY
12203-1712
US

V. Phone/Fax

Practice location:
  • Phone: 607-869-9636
  • Fax:
Mailing address:
  • Phone: 518-253-3671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number704014
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: