Healthcare Provider Details

I. General information

NPI: 1982791901
Provider Name (Legal Business Name): KATHERINE A KIRK CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHERINE FAVATA CRNA

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 DART CIR
ROME NY
13441-4229
US

IV. Provider business mailing address

105 DART CIR
ROME NY
13441-4229
US

V. Phone/Fax

Practice location:
  • Phone: 315-533-5747
  • Fax: 315-362-5120
Mailing address:
  • Phone: 315-533-5747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4844631
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4844631
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: