1740286608 NPI number — KATHLEEN HENECKE PNP

Table of content: KATHLEEN HENECKE PNP (NPI 1740286608)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740286608 NPI number — KATHLEEN HENECKE PNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENECKE
Provider First Name:
KATHLEEN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740286608
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
RD#1 CEMETARY ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FABIUS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13063
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-677-9779
Provider Business Mailing Address Fax Number:
607-753-6677

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 MAIN ST
Provider Second Line Business Practice Location Address:
STE 302
Provider Business Practice Location Address City Name:
CORTLAND
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13045-6615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-753-3798
Provider Business Practice Location Address Fax Number:
607-753-6677
Provider Enumeration Date:
06/24/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  5323055 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 363LP0200X , with the licence number: F380804-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)