Provider Demographics
NPI:1902213168
Name:SIRACUSE, KRISTEN MARIE (NP)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARIE
Last Name:SIRACUSE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:MARIE
Other - Last Name:SCHOBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:18 BIRCHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FREDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:14063-1204
Mailing Address - Country:US
Mailing Address - Phone:716-672-4600
Mailing Address - Fax:
Practice Address - Street 1:319 CENTRAL AVE
Practice Address - Street 2:LEVEL B
Practice Address - City:DUNKIRK
Practice Address - State:NY
Practice Address - Zip Code:14048-2137
Practice Address - Country:US
Practice Address - Phone:716-363-6050
Practice Address - Fax:716-363-6851
Is Sole Proprietor?:No
Enumeration Date:2014-07-18
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3385411364SF0001X
NYF338541-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04007530Medicaid