Basic Information
| Provider Information | |||||||||
| NPI: | 1861706335 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NUTTY | ||||||||
| FirstName: | KIRSTEN | ||||||||
| MiddleName: | ANN THIBODEAU | ||||||||
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| Credential: | LNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1099 COLVIN BLVD | ||||||||
| Address2: | |||||||||
| City: | KENMORE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142231904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185883235 | ||||||||
| FaxNumber: | 7163230296 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 MAIN ST FL 4 | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142031009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163230110 | ||||||||
| FaxNumber: | 7163230296 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2010 | ||||||||
| LastUpdateDate: | 01/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0222X | 382142 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics, Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 03351782 | 05 | NY | MEDICAID |