Healthcare Provider Details

I. General information

NPI: 1588640387
Provider Name (Legal Business Name): KATHLEEN ANDERSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

739 IRVING AVE
SYRACUSE NY
13210-1640
US

IV. Provider business mailing address

739 IRVING AVE
SYRACUSE NY
13210-1640
US

V. Phone/Fax

Practice location:
  • Phone: 315-479-5070
  • Fax: 315-701-2520
Mailing address:
  • Phone: 315-479-5070
  • Fax: 315-701-2520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF300236
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: