Healthcare Provider Details

I. General information

NPI: 1891118709
Provider Name (Legal Business Name): KATHLEEN MARTY YU CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2014
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 LAFAYETTE AVE
SUFFERN NY
10901-4812
US

IV. Provider business mailing address

233 LAFAYETTE AVE STE 204
SUFFERN NY
10901-5620
US

V. Phone/Fax

Practice location:
  • Phone: 845-368-5039
  • Fax: 845-368-5327
Mailing address:
  • Phone: 845-357-5775
  • Fax: 845-357-5777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number58294-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number582941
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: