Provider Demographics
NPI:1497823389
Name:WEATHERUP-OTERO, KALEANNA A (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KALEANNA
Middle Name:A
Last Name:WEATHERUP-OTERO
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 1:219 PINE ST
Mailing Address - Street 2:
Mailing Address - City:THERESA
Mailing Address - State:NY
Mailing Address - Zip Code:13691-2103
Mailing Address - Country:US
Mailing Address - Phone:315-628-4214
Mailing Address - Fax:315-628-4214
Practice Address - Street 1:219 PINE STREET
Practice Address - Street 2:
Practice Address - City:THERESA
Practice Address - State:NY
Practice Address - Zip Code:13691-0219
Practice Address - Country:US
Practice Address - Phone:315-628-4214
Practice Address - Fax:315-628-4214
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY265843164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02168183Medicaid