Provider Demographics
NPI:1891006284
Name:MONTANEZ, KATHLEEN ANNE
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:ANNE
Last Name:MONTANEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KATHLEEN
Other - Middle Name:ANNE
Other - Last Name:VALANTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:50 GERTRUDE ST
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-3212
Mailing Address - Country:US
Mailing Address - Phone:732-770-5917
Mailing Address - Fax:
Practice Address - Street 1:327 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-9426
Practice Address - Country:US
Practice Address - Phone:908-686-1212
Practice Address - Fax:908-686-7343
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02163200183500000X
OH03118900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist