Healthcare Provider Details

I. General information

NPI: 1053404061
Provider Name (Legal Business Name): KIM P GENDRON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 BLUE JAY CIR
SCHAGHTICOKE NY
12154-2950
US

IV. Provider business mailing address

19 BLUE JAY CIR
SCHAGHTICOKE NY
12154-2950
US

V. Phone/Fax

Practice location:
  • Phone: 518-470-2581
  • Fax: 518-328-8370
Mailing address:
  • Phone: 518-470-2581
  • Fax: 518-328-8370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF331800
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF401277
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: