Basic Information
| Provider Information | |||||||||
| NPI: | 1134616642 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHENGEN | ||||||||
| FirstName: | RACHAEL | ||||||||
| MiddleName: | BETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FARLEY | ||||||||
| OtherFirstName: | RACHAEL | ||||||||
| OtherMiddleName: | BETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 20 ELLEN POLIMENI BLVD APT 223 | ||||||||
| Address2: | |||||||||
| City: | CANANDAIGUA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144242251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5858132023 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 196 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | GENEVA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144561694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157874000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2018 | ||||||||
| LastUpdateDate: | 06/20/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 315734 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.