Provider Demographics
NPI:1790909547
Name:GUGLIELMO, KATRINA (RPA-C)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:GUGLIELMO
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HOWELLS RD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-5351
Mailing Address - Country:US
Mailing Address - Phone:631-666-1956
Mailing Address - Fax:631-666-1957
Practice Address - Street 1:433 LAKE AVE
Practice Address - Street 2:
Practice Address - City:SAINT JAMES
Practice Address - State:NY
Practice Address - Zip Code:11780-2207
Practice Address - Country:US
Practice Address - Phone:163-158-4601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005502207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY005502OtherNYS MEDICAL LICENSE NUMBE