Provider Demographics
NPI:1720141179
Name:REILLY-FALLON, KATHLEEN (DC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:REILLY-FALLON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 WAMPUS CLOSE
Mailing Address - Street 2:
Mailing Address - City:ARMONK
Mailing Address - State:NY
Mailing Address - Zip Code:10504-1941
Mailing Address - Country:US
Mailing Address - Phone:914-438-0232
Mailing Address - Fax:
Practice Address - Street 1:11 WAMPUS CLOSE
Practice Address - Street 2:
Practice Address - City:ARMONK
Practice Address - State:NY
Practice Address - Zip Code:10504-1941
Practice Address - Country:US
Practice Address - Phone:914-438-0232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005290213EP0504X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP0504XPodiatric Medicine & Surgery Service ProvidersPodiatristPublic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01876186Medicaid
NYU65146Medicare UPIN
NY01876186Medicaid