Provider Demographics
NPI:1306196795
Name:FENTRESS TRIPP, KATHLEEN (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:FENTRESS TRIPP
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 BERGEN AVE
Mailing Address - Street 2:JEWISH CHILD CARE ASSOCIATION
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455-1368
Mailing Address - Country:US
Mailing Address - Phone:718-742-8550
Mailing Address - Fax:718-993-4345
Practice Address - Street 1:41-43 CRESCENT STREET
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101
Practice Address - Country:US
Practice Address - Phone:718-784-2240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY654113163W00000X
NY401518363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse