Provider Demographics
NPI:1306213202
Name:WALSH, KATHLEEN (LPN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:WALSH
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 1:52 ELMHURST AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-3600
Mailing Address - Country:US
Mailing Address - Phone:631-680-0336
Mailing Address - Fax:
Practice Address - Street 1:52 ELMHURST AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-3600
Practice Address - Country:US
Practice Address - Phone:631-680-0336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143047-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse