Provider Demographics
NPI:1467439208
Name:STANEK, KATHRYN G (DC)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:G
Last Name:STANEK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 MEMORIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-5545
Mailing Address - Country:US
Mailing Address - Phone:601-799-2225
Mailing Address - Fax:601-799-4333
Practice Address - Street 1:403 MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-5545
Practice Address - Country:US
Practice Address - Phone:601-799-2225
Practice Address - Fax:601-799-4333
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS774111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117708Medicaid
MS3500000202Medicare ID - Type UnspecifiedCHIROPRACTIC
U64323Medicare UPIN