Provider Demographics
NPI:1891911335
Name:CRANDALL, KATHLEEN K (RN)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:K
Last Name:CRANDALL
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 1:113 FAIRMONT RD
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14905-2036
Mailing Address - Country:US
Mailing Address - Phone:607-732-6507
Mailing Address - Fax:
Practice Address - Street 1:113 FAIRMONT RD
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-2036
Practice Address - Country:US
Practice Address - Phone:607-732-6507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1540501163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00810095Medicaid