Provider Demographics
NPI:1053679639
Name:DIFFENDALE, KATHLEEN (RN)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:
Last Name:DIFFENDALE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 BEACH 122 STREET
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694
Mailing Address - Country:US
Mailing Address - Phone:718-318-8524
Mailing Address - Fax:718-318-2859
Practice Address - Street 1:400 BEACH 134 STREET
Practice Address - Street 2:
Practice Address - City:BELLE HARBOR
Practice Address - State:NY
Practice Address - Zip Code:11694
Practice Address - Country:US
Practice Address - Phone:718-318-8524
Practice Address - Fax:718-318-2859
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-02
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY475889163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse