Provider Demographics
NPI:1760769772
Name:GOERING, KATHLEEN (RN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:GOERING
Suffix:
Gender:F
Credentials:RN
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 657
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-0657
Mailing Address - Country:US
Mailing Address - Phone:631-208-9141
Mailing Address - Fax:
Practice Address - Street 1:199 HALSEY MANOR RD
Practice Address - Street 2:
Practice Address - City:MANORVILLE
Practice Address - State:NY
Practice Address - Zip Code:11949-1609
Practice Address - Country:US
Practice Address - Phone:631-208-9141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-05
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY241812164W00000X
NY695758163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse