Provider Demographics
NPI:1679063960
Name:MINER, MARY KATHLEEN (RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:MINER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 OAKDALE CT
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13207-2535
Mailing Address - Country:US
Mailing Address - Phone:315-880-6729
Mailing Address - Fax:
Practice Address - Street 1:526 OLD LIVERPOOL RD STE 9
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-6285
Practice Address - Country:US
Practice Address - Phone:315-453-3911
Practice Address - Fax:315-453-0197
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY566369163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420800Medicaid