Healthcare Provider Details

I. General information

NPI: 1730627787
Provider Name (Legal Business Name): KAELYN TOOLEY RN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2017
Last Update Date: 02/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 JAMES ST
SYRACUSE NY
13203-2730
US

IV. Provider business mailing address

1045 JAMES ST
SYRACUSE NY
13203-2730
US

V. Phone/Fax

Practice location:
  • Phone: 315-413-7865
  • Fax: 315-479-7884
Mailing address:
  • Phone: 315-413-7865
  • Fax: 315-479-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number636703-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF340802-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: