Healthcare Provider Details

I. General information

NPI: 1366465593
Provider Name (Legal Business Name): KELLI LEIGH PATENAUDE D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 HUDSON AVE.
STILLWATER NY
12170-0427
US

IV. Provider business mailing address

P.O. BOX 427
STILLWATER NY
12170-0427
US

V. Phone/Fax

Practice location:
  • Phone: 518-664-4525
  • Fax: 518-664-1256
Mailing address:
  • Phone: 518-664-4525
  • Fax: 518-664-1256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number011154
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: