Healthcare Provider Details

I. General information

NPI: 1033723226
Provider Name (Legal Business Name): KAELEE BOULERIS ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2020
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 COUNTY ROUTE 70
STILLWATER NY
12170-2000
US

IV. Provider business mailing address

203 COUNTY ROUTE 70
STILLWATER NY
12170-2000
US

V. Phone/Fax

Practice location:
  • Phone: 518-779-5540
  • Fax:
Mailing address:
  • Phone: 518-779-5540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number104729
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: