Provider Demographics
NPI:1619022217
Name:LANKFORD-PURNELL, KUTRESA K (CAC)
Entity Type:Individual
Prefix:
First Name:KUTRESA
Middle Name:K
Last Name:LANKFORD-PURNELL
Suffix:
Gender:F
Credentials:CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8133 CATBIRD LN
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-2822
Mailing Address - Country:US
Mailing Address - Phone:410-641-3558
Mailing Address - Fax:
Practice Address - Street 1:POCOMOKE HEALTH CENTER
Practice Address - Street 2:400A WALNUT STREET
Practice Address - City:POCOMOKE
Practice Address - State:MD
Practice Address - Zip Code:21851
Practice Address - Country:US
Practice Address - Phone:410-957-2005
Practice Address - Fax:410-957-2417
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC0487101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS013Medicare ID - Type Unspecified