Provider Demographics
NPI:1114953718
Name:KINNE, BEVERLY H (NP)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:H
Last Name:KINNE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2000
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12534-2000
Mailing Address - Country:US
Mailing Address - Phone:518-828-8363
Mailing Address - Fax:518-697-3388
Practice Address - Street 1:358 MOUNTAIN VIEW RD
Practice Address - Street 2:
Practice Address - City:COPAKE
Practice Address - State:NY
Practice Address - Zip Code:12516-1239
Practice Address - Country:US
Practice Address - Phone:518-392-3900
Practice Address - Fax:518-392-1040
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302098363LA2200X
NY360033363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW79533OtherMEDICARE GROUP ; COLUMBIA MEMORIAL HOSPITAL
NY01909517Medicaid
NYW79533OtherMEDICARE GROUP ; COLUMBIA MEMORIAL HOSPITAL
NY01909517Medicaid