Provider Demographics
NPI:1093784704
Name:HALVONIK, KELLY JEAN (RPAC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:HALVONIK
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JEAN
Other - Last Name:FARDINK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:INTERLAKES ONCOLOGY & HEMATOLOGY PC
Mailing Address - Street 2:211 WHITE SPRUCE BLVD.
Mailing Address - City:ROCHESTER,
Mailing Address - State:NY
Mailing Address - Zip Code:14623
Mailing Address - Country:US
Mailing Address - Phone:585-475-8728
Mailing Address - Fax:585-475-9411
Practice Address - Street 1:INTERLAKES ONCOLOGY & HEMATOLOGY PC
Practice Address - Street 2:156 WEST AVE.
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420
Practice Address - Country:US
Practice Address - Phone:585-395-0124
Practice Address - Fax:585-395-0127
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004379-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS73349Medicare UPIN
NYBB3909Medicare ID - Type Unspecified