Healthcare Provider Details

I. General information

NPI: 1861697153
Provider Name (Legal Business Name): KELLY K HEFFERNAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 MCCLELLAN ST SUITE 203 FOX AND SCHINGO PLASTIC SURGERY
SCHENECTADY NY
12304-1020
US

IV. Provider business mailing address

9 RIDGEFIELD WAY
WATERVLIET NY
12189-1667
US

V. Phone/Fax

Practice location:
  • Phone: 518-346-2358
  • Fax:
Mailing address:
  • Phone: 518-273-0458
  • Fax: 518-220-9400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF333933
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: