Healthcare Provider Details

I. General information

NPI: 1609397512
Provider Name (Legal Business Name): LANNY L CLEARY NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 06/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

396 BROADWAY
KINGSTON NY
12401-4626
US

IV. Provider business mailing address

9 HIGHLAND AVE APT 14
CATSKILL NY
12414-1753
US

V. Phone/Fax

Practice location:
  • Phone: 845-331-3131
  • Fax:
Mailing address:
  • Phone: 518-935-0417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF308198-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: