Provider Demographics
NPI:1659405819
Name:KLEIN, GAYLE LYNN
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:LYNN
Last Name:KLEIN
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 1:946 BALLYHACK RD
Mailing Address - Street 2:
Mailing Address - City:PORT CRANE
Mailing Address - State:NY
Mailing Address - Zip Code:13833-1026
Mailing Address - Country:US
Mailing Address - Phone:607-725-4802
Mailing Address - Fax:
Practice Address - Street 1:1276 UPPER FRONT ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-1011
Practice Address - Country:US
Practice Address - Phone:607-722-0354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040690183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01438802Medicaid