Healthcare Provider Details

I. General information

NPI: 1538781992
Provider Name (Legal Business Name): KARA L IMMORLICA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2020
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 READE PL FL 2
POUGHKEEPSIE NY
12601-3912
US

IV. Provider business mailing address

301 BALMVILLE LN
NEWBURGH NY
12550-1423
US

V. Phone/Fax

Practice location:
  • Phone: 845-214-1840
  • Fax:
Mailing address:
  • Phone: 845-728-4949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number343590
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: