Provider Demographics
NPI:1295391985
Name:KAG PROFESSIONAL NURSE PRACTITIONER IN ADULT HEALTH PLLC
Entity Type:Organization
Organization Name:KAG PROFESSIONAL NURSE PRACTITIONER IN ADULT HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GODBERSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:631-872-2995
Mailing Address - Street 1:32 MARLIN RD
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-3012
Mailing Address - Country:US
Mailing Address - Phone:631-872-2995
Mailing Address - Fax:
Practice Address - Street 1:3115 HORSEBLOCK RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2526
Practice Address - Country:US
Practice Address - Phone:631-872-2995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-17
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty