Provider Demographics
NPI:1326228198
Name:DONAGHUE, KADA MICHELLE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KADA
Middle Name:MICHELLE
Last Name:DONAGHUE
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 1:550 BALLANTYNE RD.
Mailing Address - Street 2:
Mailing Address - City:ROCH.
Mailing Address - State:NY
Mailing Address - Zip Code:14623
Mailing Address - Country:US
Mailing Address - Phone:585-889-5403
Mailing Address - Fax:
Practice Address - Street 1:550 BALLANTYNE RD.
Practice Address - Street 2:
Practice Address - City:ROCH.
Practice Address - State:NY
Practice Address - Zip Code:14623
Practice Address - Country:US
Practice Address - Phone:585-889-5002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2670531164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02291454Medicaid