Provider Demographics
NPI:1497912646
Name:MICHEL, KATHLEEN
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:
Last Name:MICHEL
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 1:200 OLD COUNTRY ROAD
Mailing Address - Street 2:SUITE #125
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501
Mailing Address - Country:US
Mailing Address - Phone:516-663-9098
Mailing Address - Fax:516-663-4532
Practice Address - Street 1:200 OLD COUNTRY RD
Practice Address - Street 2:SUITE #125
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4235
Practice Address - Country:US
Practice Address - Phone:516-663-9098
Practice Address - Fax:516-663-4532
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-16
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333635-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02368289Medicaid