Healthcare Provider Details

I. General information

NPI: 1033557640
Provider Name (Legal Business Name): ANDROMEDA RAINDANCE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2013
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 WASHINGTON AVE
KINGSTON NY
12401-3702
US

IV. Provider business mailing address

105 COTTONTAIL LANE
WOODSTOCK NY
12498
US

V. Phone/Fax

Practice location:
  • Phone: 845-338-7140
  • Fax:
Mailing address:
  • Phone: 845-332-7884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number355983
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number283728
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: