Healthcare Provider Details

I. General information

NPI: 1386264695
Provider Name (Legal Business Name): KERI ANN YEAGLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2020
Last Update Date: 04/17/2020
Certification Date: 04/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 MERCER ST
NEW YORK NY
10012-1502
US

IV. Provider business mailing address

3983 OLD CROMPOND RD
CORTLANDT MANOR NY
10567-7220
US

V. Phone/Fax

Practice location:
  • Phone: 212-677-3400
  • Fax:
Mailing address:
  • Phone: 914-382-6710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number302480
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: