Provider Demographics
NPI:1689142143
Name:OLMEDO, KATHERINE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:OLMEDO
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 1:105-07 HOWELLS RD
Mailing Address - Street 2:APT G2
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-2409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:998 CROOKED HILL RD
Practice Address - Street 2:
Practice Address - City:WEST BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-1019
Practice Address - Country:US
Practice Address - Phone:631-761-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-02
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY883454163W00000X
NY332702164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY332702OtherLICENCE