Provider Demographics
NPI:1619463890
Name:IM, KATRINA (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:IM
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 CROSS RIVER RD
Mailing Address - Street 2:
Mailing Address - City:KATONAH
Mailing Address - State:NY
Mailing Address - Zip Code:10536-3549
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 CROSS RIVER RD
Practice Address - Street 2:
Practice Address - City:KATONAH
Practice Address - State:NY
Practice Address - Zip Code:10536
Practice Address - Country:US
Practice Address - Phone:516-578-1246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-10
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY746849163W00000X
NY402462363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse