Provider Demographics
NPI:1215695077
Name:PENALOSA, KAZELL ANN (FNP-BC)
Entity type:Individual
Prefix:
First Name:KAZELL ANN
Middle Name:
Last Name:PENALOSA
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 SICKLES AVE
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-1829
Mailing Address - Country:US
Mailing Address - Phone:845-367-1161
Mailing Address - Fax:
Practice Address - Street 1:19 LAUREL AVE
Practice Address - Street 2:
Practice Address - City:CORNWALL
Practice Address - State:NY
Practice Address - Zip Code:12518-1403
Practice Address - Country:US
Practice Address - Phone:845-534-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY684065163W00000X
NY347643363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse