Basic Information
| Provider Information | |||||||||
| NPI: | 1245512284 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KINNALLY | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PRONG | ||||||||
| OtherFirstName: | HEIDI | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 17 LANSING ST | ||||||||
| Address2: | AUBURN MEMORIAL HOSPITAL - LIBBY WARD, MED STAFF SVS | ||||||||
| City: | AUBURN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130211983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152557202 | ||||||||
| FaxNumber: | 3152557289 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 LANSING ST | ||||||||
| Address2: | AUBURN MEMORIAL HOSPITAL - LIBBY WARD, MED STAFF SVS | ||||||||
| City: | AUBURN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130211983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152557202 | ||||||||
| FaxNumber: | 3152557289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2011 | ||||||||
| LastUpdateDate: | 09/15/2011 | ||||||||
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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 | 363LP0808X | F401384-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.