Provider Demographics
NPI:1164680666
Name:MINYARD, KATHLEEN MARY (RN)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:MARY
Last Name:MINYARD
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 1:254 FRANKLIN STREET
Mailing Address - Street 2:LAKE SHORE BEHAVIORAL HEALTH
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202
Mailing Address - Country:US
Mailing Address - Phone:716-842-0440
Mailing Address - Fax:716-842-4069
Practice Address - Street 1:430 NIAGARA STREET
Practice Address - Street 2:ACT PROGRAM
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14201
Practice Address - Country:US
Practice Address - Phone:716-856-2587
Practice Address - Fax:716-856-2608
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5747401163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5747401OtherREGISTERED NURSE