Healthcare Provider Details

I. General information

NPI: 1083365043
Provider Name (Legal Business Name): KIETHAN LANCE BOYD NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2022
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 MONROE AVE
ROCHESTER NY
14607-3632
US

IV. Provider business mailing address

259 MONROE AVE
ROCHESTER NY
14607-3632
US

V. Phone/Fax

Practice location:
  • Phone: 585-545-7200
  • Fax: 585-244-8177
Mailing address:
  • Phone: 585-545-7200
  • Fax: 585-232-1553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number348207
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: