Healthcare Provider Details

I. General information

NPI: 1750245841
Provider Name (Legal Business Name): KATHERINE NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

792 N MAIN ST STE 100C
NORTH SYRACUSE NY
13212-1667
US

IV. Provider business mailing address

792 N MAIN ST STE 100C
NORTH SYRACUSE NY
13212-1667
US

V. Phone/Fax

Practice location:
  • Phone: 315-458-2552
  • Fax: 315-458-2575
Mailing address:
  • Phone: 315-458-2552
  • Fax: 315-458-2575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number055302
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: