Provider Demographics
NPI:1083162838
Name:CAMPOVERDE AREVALO, KATHERINE BERENICE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:BERENICE
Last Name:CAMPOVERDE AREVALO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9838 57TH AVE APT 2J
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-4918
Mailing Address - Country:US
Mailing Address - Phone:347-724-5845
Mailing Address - Fax:
Practice Address - Street 1:1157 BILLIGS CT SE
Practice Address - Street 2:AP# 1A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508
Practice Address - Country:US
Practice Address - Phone:347-724-5845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY524398310247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other