Provider Demographics
NPI:1689767790
Name:TANNEY, KATHLEEN ANN (FNP-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
Last Name:TANNEY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:ANN
Other - Last Name:CREEDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:183 FENTON RD
Mailing Address - Street 2:
Mailing Address - City:WEST WINFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:13491-4110
Mailing Address - Country:US
Mailing Address - Phone:315-263-5984
Mailing Address - Fax:
Practice Address - Street 1:230 N GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-2529
Practice Address - Country:US
Practice Address - Phone:315-275-3214
Practice Address - Fax:315-275-3215
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF331634363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00354485Medicaid
NY00354485Medicaid
NY330218Medicare ID - Type Unspecified