Provider Demographics
NPI:1265587117
Name:KLAUSNER, THERESA INTILLI (MS, APRN, BC, FNP)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:INTILLI
Last Name:KLAUSNER
Suffix:
Gender:F
Credentials:MS, APRN, BC, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 EAST STATE STREET
Mailing Address - Street 2:PO BOX 1250
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078-0010
Mailing Address - Country:US
Mailing Address - Phone:518-775-4205
Mailing Address - Fax:518-775-4225
Practice Address - Street 1:4104 STATE HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-6202
Practice Address - Country:US
Practice Address - Phone:518-883-8620
Practice Address - Fax:518-883-5653
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333567-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF333567-1OtherSTATE LICENSE NUMBER
NYRA7650Medicare PIN
NYQ49760Medicare UPIN