Healthcare Provider Details

I. General information

NPI: 1497098305
Provider Name (Legal Business Name): CHEYENNE CARDAMONE-KNEWSTUB RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2013
Last Update Date: 03/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 W BUFFALO ST
ITHACA NY
14850-4124
US

IV. Provider business mailing address

302 W BUFFALO ST
ITHACA NY
14850-4124
US

V. Phone/Fax

Practice location:
  • Phone: 607-274-2210
  • Fax: 607-274-2196
Mailing address:
  • Phone: 607-274-2210
  • Fax: 607-274-2196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number22 658227
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: