Provider Demographics
NPI:1679191019
Name:HALLECK, KATHERINE ROSE (FNP-C)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ROSE
Last Name:HALLECK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 ATKINSON AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13207-1125
Mailing Address - Country:US
Mailing Address - Phone:315-450-7227
Mailing Address - Fax:
Practice Address - Street 1:141 ATKINSON AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13207-1125
Practice Address - Country:US
Practice Address - Phone:315-450-7227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY346108363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF07200068OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS