Provider Demographics
NPI:1326680596
Name:SNOW, KATHLEEN VAJDA
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:VAJDA
Last Name:SNOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 S MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-5808
Mailing Address - Country:US
Mailing Address - Phone:336-722-7266
Mailing Address - Fax:336-201-0538
Practice Address - Street 1:713 S MARSHALL ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-5808
Practice Address - Country:US
Practice Address - Phone:336-722-7266
Practice Address - Fax:336-201-0538
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC299062163W00000X
MDAC003827363LP0808X
NC5012939363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
299062OtherRN LICENSE