1154312593 NPI number — KATHY LYNN HERREN PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154312593 NPI number — KATHY LYNN HERREN PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERREN
Provider First Name:
KATHY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAZUR - HERREN
Provider Other First Name:
KATHY
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1154312593
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 304
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENS FALLS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12801-0304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-926-6992
Provider Business Mailing Address Fax Number:
518-926-6983

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
135 NORTH ROAD
Provider Second Line Business Practice Location Address:
WILTON FAMILY MEDICINE
Provider Business Practice Location Address City Name:
WILTON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-926-1935
Provider Business Practice Location Address Fax Number:
518-926-4804
Provider Enumeration Date:
11/03/2005

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: 363A00000X , with the licence number:  004509 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02352454 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".