Provider Demographics
NPI:1750052734
Name:RODER, KATHY MARIE (RN)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:MARIE
Last Name:RODER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:MARIE
Other - Last Name:SWEET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1 CHIMNEY POINT DR
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-2212
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 CHIMNEY POINT DR
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-2212
Practice Address - Country:US
Practice Address - Phone:315-542-2478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY671718-01163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent