Healthcare Provider Details

I. General information

NPI: 1083970529
Provider Name (Legal Business Name): KATHLEEN SPETA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 11/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 LODER ST 191 NORTH MAIN STREET
WELLSVILLE NY
14895-1112
US

IV. Provider business mailing address

256 CENTER RD
WEST SENECA NY
14224-1947
US

V. Phone/Fax

Practice location:
  • Phone: 585-596-4129
  • Fax: 585-596-0653
Mailing address:
  • Phone: 716-677-4159
  • Fax: 716-677-4470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberF3370711
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF3370711
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: