Provider Demographics
NPI:1427571835
Name:KERESEY, KATELYN JANICE
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:JANICE
Last Name:KERESEY
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 1:26 OLD STAGECOACH RD
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:ME
Mailing Address - Zip Code:04468-4332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6501 E GREENWAY PKWY
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-2025
Practice Address - Country:US
Practice Address - Phone:480-991-2373
Practice Address - Fax:480-991-2036
Is Sole Proprietor?:No
Enumeration Date:2017-07-18
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPI45590390200000X
COS024143183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program