Provider Demographics
NPI:1093197857
Name:COFFEY, KATELYNN ANN (NP)
Entity Type:Individual
Prefix:
First Name:KATELYNN
Middle Name:ANN
Last Name:COFFEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KATELYNN
Other - Middle Name:ANN
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1561 LONG POND RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4117
Mailing Address - Country:US
Mailing Address - Phone:585-723-7778
Mailing Address - Fax:585-723-7925
Practice Address - Street 1:2350 RIDGEWAY AVE STE B
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4127
Practice Address - Country:US
Practice Address - Phone:585-922-0900
Practice Address - Fax:585-225-1921
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF307332363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04194496Medicaid
NY04194496Medicaid
NYJ400236814/GRPBA0017Medicare PIN