Provider Demographics
NPI:1902357106
Name:TOM, KATHERINE (PPCNP-BC)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:TOM
Suffix:
Gender:F
Credentials:PPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:564 1ST AVE APT 12G
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6484
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 HEYWARD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-2966
Practice Address - Country:US
Practice Address - Phone:718-302-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-23
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.447168163W00000X
IL209.014967363LP0200X
NY383024363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse