1679078240 NPI number — DR. KATHLEEN SIOBHAN BLEAKNEY-HANLON ND

Table of content: DR. KATHLEEN SIOBHAN BLEAKNEY-HANLON ND (NPI 1679078240)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679078240 NPI number — DR. KATHLEEN SIOBHAN BLEAKNEY-HANLON ND

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLEAKNEY-HANLON
Provider First Name:
KATHLEEN
Provider Middle Name:
SIOBHAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
ND
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:
1679078240
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
292 S COUNTRY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
E PATCHOGUE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11772-5454
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-394-0399
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
734 MONTAUK HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAYPORT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11705-1621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-394-0399
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2018

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: 175F00000X , with the licence number:  099.0087995 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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