Basic Information
| Provider Information | |||||||||
| NPI: | 1740286608 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENECKE | ||||||||
| FirstName: | KATHLEEN | ||||||||
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| Credential: | PNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | RD#1 CEMETARY ROAD | ||||||||
| Address2: | |||||||||
| City: | FABIUS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3156779779 | ||||||||
| FaxNumber: | 6077536677 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 MAIN ST | ||||||||
| Address2: | STE 302 | ||||||||
| City: | CORTLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130456615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077533798 | ||||||||
| FaxNumber: | 6077536677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 5323055 | NY | X | Nursing Service Providers | Registered Nurse | 363LP0200X | F380804-1 | NY | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.