Provider Demographics
NPI:1003913823
Name:NISHIDA, KATHLEEN M (CNM)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:M
Last Name:NISHIDA
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:MS
Other - First Name:KATHLEEN
Other - Middle Name:M
Other - Last Name:RAFFLOER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:1401 S 31ST ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-3506
Mailing Address - Country:US
Mailing Address - Phone:215-925-2400
Mailing Address - Fax:215-925-9162
Practice Address - Street 1:4510 FRANKFORD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-3602
Practice Address - Country:US
Practice Address - Phone:215-744-1302
Practice Address - Fax:215-744-2544
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMW008566L176B00000X
PARN355082L163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001792598Medicaid