1447527841 NPI number — MISS KATHLEEN MAE ROBERTS LPN

Table of content: MISS KATHLEEN MAE ROBERTS LPN (NPI 1447527841)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447527841 NPI number — MISS KATHLEEN MAE ROBERTS LPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
KATHLEEN
Provider Middle Name:
MAE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
LPN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447527841
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
41 OCONNOR RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRPORT
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14450-1327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-328-3360
Provider Business Mailing Address Fax Number:
585-794-5029

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
41 OCONNOR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRPORT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14450-1327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-328-3360
Provider Business Practice Location Address Fax Number:
585-794-5029
Provider Enumeration Date:
11/30/2011

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: 164W00000X , with the licence number:  2334001 , 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: 164W00000 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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