Provider Demographics
NPI:1669758199
Name:CUNNINGHAM, KATHERINE MCDERMOTT (MSN, CPNP)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:MCDERMOTT
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:MSN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 IRVING AVE
Mailing Address - Street 2:SUITE 804
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1603
Mailing Address - Country:US
Mailing Address - Phone:315-214-7700
Mailing Address - Fax:315-214-7701
Practice Address - Street 1:725 IRVING AVE
Practice Address - Street 2:SUITE 804
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1603
Practice Address - Country:US
Practice Address - Phone:315-214-7700
Practice Address - Fax:315-214-7701
Is Sole Proprietor?:No
Enumeration Date:2011-10-28
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY382207363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03389035Medicaid
NYJ400059424Medicare PIN