MEDICARE: KELLY JEANNE KNICKERBOCKER CNM

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	176B00000X	Midwife

General Provider Information

NPI Number	:	1912863416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY JEANNE KNICKERBOCKER CNM

Provider Business Mailing Address
First Line	:	2000 EMPIRE BLVD STE 200
Second Line	:
City	:	WEBSTER
State	:	NY
Zip	:	14580-1957
Country	:	US
Telephone Number	:	585-922-0374
Fax Number	:

Provider Business Practice Location Address
First Line	:	2000 EMPIRE BLVD STE 200
Second Line	:
City	:	WEBSTER
State	:	NY
Zip	:	14580-1957
Country	:	US
Telephone Number	:	585-922-0374
Fax Number	:

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

Provider Enumeration Date	:	12/29/2025
Last Update Date	:	12/29/2025

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