Provider Demographics
NPI:1740286608
Name:HENECKE, KATHLEEN (PNP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:HENECKE
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RD#1 CEMETARY ROAD
Mailing Address - Street 2:
Mailing Address - City:FABIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13063
Mailing Address - Country:US
Mailing Address - Phone:315-677-9779
Mailing Address - Fax:607-753-6677
Practice Address - Street 1:17 MAIN ST
Practice Address - Street 2:STE 302
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-6615
Practice Address - Country:US
Practice Address - Phone:607-753-3798
Practice Address - Fax:607-753-6677
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5323055163W00000X
NYF380804-1363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYDD1345Medicare ID - Type Unspecified
NYP60383Medicare UPIN