1962788034 NPI number — DR. KATHLEEN CONDRY HARLEY N.D.

Table of content: DR. KATHLEEN CONDRY HARLEY N.D. (NPI 1962788034)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962788034 NPI number — DR. KATHLEEN CONDRY HARLEY N.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARLEY
Provider First Name:
KATHLEEN
Provider Middle Name:
CONDRY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
N.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HARLEY
Provider Other First Name:
KATHLEEN
Provider Other Middle Name:
CONDRY
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
ND
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1962788034
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
712 D ST STE I
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN RAFAEL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94901-3706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-721-7453
Provider Business Mailing Address Fax Number:
415-721-7454

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 BEL MARIN KEYS BLVD STE D2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NOVATO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94949-5709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-721-7453
Provider Business Practice Location Address Fax Number:
415-721-7454
Provider Enumeration Date:
11/02/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ND-481 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 405300000X , with the licence number: ND-481 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 175F00000X , with the licence number: ND-481 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)