Provider Demographics
NPI:1366128167
Name:ILSE, KAYANI
Entity type:Individual
Prefix:
First Name:KAYANI
Middle Name:
Last Name:ILSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:778 COUNTY ROUTE 7
Mailing Address - Street 2:
Mailing Address - City:EAST SCHODACK
Mailing Address - State:NY
Mailing Address - Zip Code:12063
Mailing Address - Country:US
Mailing Address - Phone:831-295-1221
Mailing Address - Fax:
Practice Address - Street 1:778 COUNTY ROUTE 7
Practice Address - Street 2:
Practice Address - City:EAST SCHODACK
Practice Address - State:NY
Practice Address - Zip Code:12063
Practice Address - Country:US
Practice Address - Phone:831-295-1221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1394728201174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty