Provider Demographics
NPI:1629496476
Name:STORER, KATHLEEN MARIE (CRNA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:STORER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11781 LEE JACKSON MEMORIAL HWY
Mailing Address - Street 2:SUITE 550
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033
Mailing Address - Country:US
Mailing Address - Phone:571-777-5102
Mailing Address - Fax:703-563-6256
Practice Address - Street 1:100 FAIRFIELD DR
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:PA
Practice Address - Zip Code:16346-2130
Practice Address - Country:US
Practice Address - Phone:814-676-7992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-30
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN326516L367500000X
NY431896-1367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA365508Medicare PIN