Provider Demographics
NPI:1073789236
Name:LAGRECA, KATHLEEN MARIE (RN)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:LAGRECA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:KATHLEEN
Other - Middle Name:MARIE
Other - Last Name:BLUMENTHAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:4 OAKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON BAYS
Mailing Address - State:NY
Mailing Address - Zip Code:11946-3611
Mailing Address - Country:US
Mailing Address - Phone:631-728-6308
Mailing Address - Fax:
Practice Address - Street 1:4 OAKWOOD RD
Practice Address - Street 2:
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946-3611
Practice Address - Country:US
Practice Address - Phone:631-728-6308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY282164163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY282164OtherRN LICENSE
NY02745393OtherMEDICAID PROVIDER