Provider Demographics
NPI:1710533450
Name:VUKONICH, KATHLEEN A
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:VUKONICH
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:PO BOX 57
Mailing Address - Street 2:
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740-0057
Mailing Address - Country:US
Mailing Address - Phone:575-445-5615
Mailing Address - Fax:
Practice Address - Street 1:200 SOUTHWELL MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-3864
Practice Address - Country:US
Practice Address - Phone:575-445-5615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider