Provider Demographics
NPI:1619977949
Name:MARSHALL, KATHLEEN M (NP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11-719
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12211
Mailing Address - Country:US
Mailing Address - Phone:518-782-7133
Mailing Address - Fax:518-782-7155
Practice Address - Street 1:582 NEW LOUDON RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-4029
Practice Address - Country:US
Practice Address - Phone:518-389-7133
Practice Address - Fax:518-782-7155
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332707363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02041541Medicaid
NY02041541Medicaid
BB9386Medicare PIN