Provider Demographics
NPI:1518557131
Name:BYNUM, KATHLEEN ANN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
Last Name:BYNUM
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 1:310 W CANAL ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-3308
Mailing Address - Country:US
Mailing Address - Phone:937-470-7549
Mailing Address - Fax:
Practice Address - Street 1:4822 WALDEN LN
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-5527
Practice Address - Country:US
Practice Address - Phone:937-470-7549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5055145374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5055145OtherDODD- CONTRACT NUMBER