Healthcare Provider Details

I. General information

NPI: 1164050308
Provider Name (Legal Business Name): ANGIE E KILBURN NP ADULT HEALTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 03/07/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 BAY RD STE 1
QUEENSBURY NY
12804-3012
US

IV. Provider business mailing address

147 JAMES RD
SALEM NY
12865-5030
US

V. Phone/Fax

Practice location:
  • Phone: 518-932-7234
  • Fax:
Mailing address:
  • Phone: 518-414-8322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberF310837-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: