Provider Demographics
NPI:1457889800
Name:ANDERSON, KATHLEEN DIANE (FNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:DIANE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:BOECK
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:152 OLD STATE HIGHWAY 8 N
Mailing Address - Street 2:
Mailing Address - City:MOUNT UPTON
Mailing Address - State:NY
Mailing Address - Zip Code:13809-4230
Mailing Address - Country:US
Mailing Address - Phone:607-867-4018
Mailing Address - Fax:
Practice Address - Street 1:152 OLD STATE HIGHWAY 8 N
Practice Address - Street 2:
Practice Address - City:MOUNT UPTON
Practice Address - State:NY
Practice Address - Zip Code:13809-4230
Practice Address - Country:US
Practice Address - Phone:607-867-4018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY341758363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily