Provider Demographics
NPI:1962104505
Name:NILAND, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:NILAND
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 1:313 LANSDOWNE RD
Mailing Address - Street 2:
Mailing Address - City:DE WITT
Mailing Address - State:NY
Mailing Address - Zip Code:13214-2128
Mailing Address - Country:US
Mailing Address - Phone:315-256-2871
Mailing Address - Fax:
Practice Address - Street 1:4317 E GENESEE ST
Practice Address - Street 2:ST. 210
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13214-2114
Practice Address - Country:US
Practice Address - Phone:315-256-2871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY340817363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily