Provider Demographics
NPI:1861912206
Name:CANNIZZARO, KYM M (NP)
Entity type:Individual
Prefix:
First Name:KYM
Middle Name:M
Last Name:CANNIZZARO
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 1:9097 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLARENCE
Mailing Address - State:NY
Mailing Address - Zip Code:14031-1965
Mailing Address - Country:US
Mailing Address - Phone:716-759-4938
Mailing Address - Fax:716-759-4939
Practice Address - Street 1:9097 MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARENCE
Practice Address - State:NY
Practice Address - Zip Code:14031-1965
Practice Address - Country:US
Practice Address - Phone:716-759-4938
Practice Address - Fax:716-759-4938
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308214363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health