Healthcare Provider Details

I. General information

NPI: 1245512284
Provider Name (Legal Business Name): HEIDI MARIE KINNALLY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEIDI MARIE PRONG

II. Dates (important events)

Enumeration Date: 09/15/2011
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
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: 315-472-4471
  • Fax: 315-472-1759
Mailing address:
  • Phone: 315-472-4471
  • Fax: 315-472-1759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF401384-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: