Provider Demographics
NPI:1255656252
Name:BOOTH, KATHY (LPN)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:BOOTH
Suffix:
Gender:F
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:PO BOX 183
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-0183
Mailing Address - Country:US
Mailing Address - Phone:315-782-9285
Mailing Address - Fax:315-782-9289
Practice Address - Street 1:21107 COFFEEN ST.
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601
Practice Address - Country:US
Practice Address - Phone:315-782-9285
Practice Address - Fax:315-782-9289
Is Sole Proprietor?:No
Enumeration Date:2010-04-01
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY257538-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse