Healthcare Provider Details

I. General information

NPI: 1962069716
Provider Name (Legal Business Name): KELSIE RAE FOURNIER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2019
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 COUNTY ROUTE 51
MALONE NY
12953-4504
US

IV. Provider business mailing address

380 COUNTY ROUTE 51
MALONE NY
12953-4504
US

V. Phone/Fax

Practice location:
  • Phone: 518-483-2600
  • Fax: 518-483-0115
Mailing address:
  • Phone: 518-483-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: