Provider Demographics
NPI:1942517297
Name:WALDOW, KATHLEEN A
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:A
Last Name:WALDOW
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KATHLEEN
Other - Middle Name:A
Other - Last Name:WALDOW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:IBCLC
Mailing Address - Street 1:165 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11001-3305
Mailing Address - Country:US
Mailing Address - Phone:516-270-3159
Mailing Address - Fax:
Practice Address - Street 1:165 LOCUST ST
Practice Address - Street 2:
Practice Address - City:FLORAL PARK
Practice Address - State:NY
Practice Address - Zip Code:11001-3305
Practice Address - Country:US
Practice Address - Phone:516-270-3159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA10117173174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist