Basic Information
| Provider Information | |||||||||
| NPI: | 1356847545 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YORKE | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PIZZIMENTI | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 161 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PORT JERVIS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 127712113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8458563284 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 161 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PORT JERVIS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 127712113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8458563284 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2018 | ||||||||
| LastUpdateDate: | 10/04/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F342869-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 05106712 | 05 | NY | MEDICAID |