Provider Demographics
NPI:1891023446
Name:KNACKE, KATHLEEN (LPN)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:
Last Name:KNACKE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 ADAMS PL
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-1810
Mailing Address - Country:US
Mailing Address - Phone:631-539-9598
Mailing Address - Fax:
Practice Address - Street 1:200 HOWELLS RD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-5351
Practice Address - Country:US
Practice Address - Phone:631-665-5906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-19
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY288654164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse