Provider Demographics
NPI:1114109162
Name:STITH, KEVIN L (LPN)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:L
Last Name:STITH
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 FERNCLIFF AVE
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-6410
Mailing Address - Country:US
Mailing Address - Phone:315-451-4012
Mailing Address - Fax:
Practice Address - Street 1:1868 WILLOWDALE RD
Practice Address - Street 2:
Practice Address - City:SKANEATELES
Practice Address - State:NY
Practice Address - Zip Code:13152-8605
Practice Address - Country:US
Practice Address - Phone:315-673-4075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-02
Last Update Date:2007-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY267360164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02263289Medicaid