1972176071 NPI number — KATHRYN ELIZABETH FUNK ACAGNP-BC

Table of content: KATHRYN ELIZABETH FUNK ACAGNP-BC (NPI 1972176071)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972176071 NPI number — KATHRYN ELIZABETH FUNK ACAGNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FUNK
Provider First Name:
KATHRYN
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ACAGNP-BC
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:
1972176071
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 639971
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45263-9971
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1002 BON SECOURS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUFFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-541-1110
Provider Business Practice Location Address Fax Number:
757-541-1119
Provider Enumeration Date:
07/19/2021

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: 363LA2200X , with the licence number:  0024182240 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NONE . This is a "I HAVE NONE" identifier . This identifiers is of the category "OTHER".




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