Healthcare Provider Details

I. General information

NPI: 1114892049
Provider Name (Legal Business Name): ROBIN LEE GAVIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2025
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 WARREN RD
ITHACA NY
14850-1862
US

IV. Provider business mailing address

850 STEAM MILL RD
ITHACA NY
14850-9423
US

V. Phone/Fax

Practice location:
  • Phone: 607-257-1555
  • Fax:
Mailing address:
  • Phone: 607-257-1555
  • Fax: 607-697-8220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number327495
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: