Basic Information
| Provider Information | |||||||||
| NPI: | 1134361942 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANLIESHOUT | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | KATHERINE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 138 NORTH COURT ST | ||||||||
| Address2: | |||||||||
| City: | WAMPSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153662327 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 201 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | ONEIDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134212111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153618413 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2009 | ||||||||
| LastUpdateDate: | 03/26/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 242891-1 | NY | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 00569860 | 05 | NY | MEDICAID |