Provider Demographics
NPI:1093262180
Name:WIRTENSON, CATHY
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:
Last Name:WIRTENSON
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 1:28 WAINWRIGHT ST
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-4713
Mailing Address - Country:US
Mailing Address - Phone:631-494-9768
Mailing Address - Fax:
Practice Address - Street 1:28 WAINWRIGHT ST
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-4713
Practice Address - Country:US
Practice Address - Phone:631-494-9768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY352222-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse