Provider Demographics
NPI:1558683730
Name:KUDRICK, KERRILYNN
Entity Type:Individual
Prefix:
First Name:KERRILYNN
Middle Name:
Last Name:KUDRICK
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 1:320 THRIFT ST
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-6235
Mailing Address - Country:US
Mailing Address - Phone:631-987-6436
Mailing Address - Fax:
Practice Address - Street 1:320 THRIFT ST
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-6235
Practice Address - Country:US
Practice Address - Phone:631-987-6436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY246294164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse