Basic Information
Provider Information | |||||||||
NPI: | 1265587117 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KLAUSNER | ||||||||
FirstName: | THERESA | ||||||||
MiddleName: | INTILLI | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS, APRN, BC, FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 99 EAST STATE STREET | ||||||||
Address2: | PO BOX 1250 | ||||||||
City: | GLOVERSVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 120780010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5187754205 | ||||||||
FaxNumber: | 5187754225 | ||||||||
Practice Location | |||||||||
Address1: | 4104 STATE HIGHWAY 30 | ||||||||
Address2: |   | ||||||||
City: | AMSTERDAM | ||||||||
State: | NY | ||||||||
PostalCode: | 120106202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5188838620 | ||||||||
FaxNumber: | 5188835653 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/23/2007 | ||||||||
LastUpdateDate: | 10/19/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F333567-1 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | F333567-1 | 01 | NY | STATE LICENSE NUMBER | OTHER |