Provider Demographics
NPI:1043691637
Name:SCANLON, KATIE ELIZABETH
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:ELIZABETH
Last Name:SCANLON
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:PO BOX 7
Mailing Address - Street 2:
Mailing Address - City:SALISBURY CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:13454-0007
Mailing Address - Country:US
Mailing Address - Phone:315-717-2100
Mailing Address - Fax:
Practice Address - Street 1:170 BURWELL ST
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:NY
Practice Address - Zip Code:13365-1716
Practice Address - Country:US
Practice Address - Phone:315-823-4546
Practice Address - Fax:315-823-4760
Is Sole Proprietor?:No
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY339639363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily