Provider Demographics
NPI:1558025775
Name:TAVERNIA, KYLIE MAE
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:MAE
Last Name:TAVERNIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 FINNEY BLVD
Mailing Address - Street 2:
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12953-1067
Mailing Address - Country:US
Mailing Address - Phone:518-483-1251
Mailing Address - Fax:
Practice Address - Street 1:1225 STATE ROUTE 122
Practice Address - Street 2:
Practice Address - City:CONSTABLE
Practice Address - State:NY
Practice Address - Zip Code:12926-3006
Practice Address - Country:US
Practice Address - Phone:518-651-0487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No376K00000XNursing Service Related ProvidersNurse's Aide