MEDICARE: KELLY DUESLER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1922257872	OTHER	NY	AGENCY NPI

General Provider Information

NPI Number	:	1407498504
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY DUESLER

Provider Business Mailing Address
First Line	:	15 SUFFERN PL STE B
Second Line	:
City	:	SUFFERN
State	:	NY
Zip	:	10901-5566
Country	:	US
Telephone Number	:	845-369-4058
Fax Number	:

Provider Business Practice Location Address
First Line	:	15 SUFFERN PL STE B
Second Line	:
City	:	SUFFERN
State	:	NY
Zip	:	10901-5566
Country	:	US
Telephone Number	:	845-369-4058
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2019
Last Update Date	:	10/10/2019

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