Basic Information
| Provider Information | |||||||||
| NPI: | 1174126999 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEJONGE | ||||||||
| FirstName: | KERRI | ||||||||
| MiddleName: | KATHLEEN | ||||||||
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| Credential: | RNFA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 KINGS HWY S | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146175504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154622636 | ||||||||
| FaxNumber: | 3154622638 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 COULTER RD STE 2605 | ||||||||
| Address2: | |||||||||
| City: | CLIFTON SPRINGS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144321122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154622636 | ||||||||
| FaxNumber: | 3154622638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2020 | ||||||||
| LastUpdateDate: | 11/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WR0006X | 529593 | NY | Y | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant |
No ID Information.