Provider Demographics
NPI:1912997123
Name:TIBBITS, KATHLEEN GRACE (FNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:GRACE
Last Name:TIBBITS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5794 WIDEWATERS PKWY
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214-1845
Mailing Address - Country:US
Mailing Address - Phone:315-422-1513
Mailing Address - Fax:315-476-5950
Practice Address - Street 1:721 E GENESEE ST
Practice Address - Street 2:FL 2
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1505
Practice Address - Country:US
Practice Address - Phone:315-476-3124
Practice Address - Fax:315-476-3136
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2020-07-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NYF331892-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00561353Medicaid
NY00561353Medicaid
NYBB3639Medicare PIN