Provider Demographics
NPI:1225563398
Name:KIRK, KALLEA (LPN)
Entity Type:Individual
Prefix:
First Name:KALLEA
Middle Name:
Last Name:KIRK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:KALLEA
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:9790 GLENMORE RD
Mailing Address - Street 2:
Mailing Address - City:TABERG
Mailing Address - State:NY
Mailing Address - Zip Code:13471-2028
Mailing Address - Country:US
Mailing Address - Phone:315-335-0906
Mailing Address - Fax:
Practice Address - Street 1:9790 GLENMORE RD
Practice Address - Street 2:
Practice Address - City:TABERG
Practice Address - State:NY
Practice Address - Zip Code:13471-2028
Practice Address - Country:US
Practice Address - Phone:315-335-0906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307144-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse