Provider Demographics
NPI:1366685745
Name:MCHOLDER, KIA L
Entity Type:Individual
Prefix:
First Name:KIA
Middle Name:L
Last Name:MCHOLDER
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 1:89 CARSON AVE
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-5920
Mailing Address - Country:US
Mailing Address - Phone:845-568-5645
Mailing Address - Fax:845-568-5645
Practice Address - Street 1:89 CARSON AVE
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-5920
Practice Address - Country:US
Practice Address - Phone:845-568-5645
Practice Address - Fax:845-568-5645
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-14
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY284267-1164W00000X, 164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse