1427496561 NPI number — KERRY ELIZABETH MILLEA A.N.P.

Table of content: KERRY ELIZABETH MILLEA A.N.P. (NPI 1427496561)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427496561 NPI number — KERRY ELIZABETH MILLEA A.N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLEA
Provider First Name:
KERRY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
A.N.P.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KEENAN
Provider Other First Name:
KERRY
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1427496561
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
711 TROY SCHENECTADY RD
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
LATHAM
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12110-2442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-782-3700
Provider Business Mailing Address Fax Number:
518-782-3799

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 DELAWARE AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
DELMAR
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12054-1401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-439-8077
Provider Business Practice Location Address Fax Number:
518-438-8070
Provider Enumeration Date:
06/11/2013

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: 363LA2200X , with the licence number:  F306479-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03688415 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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