Provider Demographics
NPI:1013061621
Name:KITTERMAN, KATY
Entity Type:Individual
Prefix:
First Name:KATY
Middle Name:
Last Name:KITTERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 N WOODLAWN BLVD
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-2922
Mailing Address - Country:US
Mailing Address - Phone:316-788-5533
Mailing Address - Fax:316-788-7432
Practice Address - Street 1:1412 N WOODLAWN BLVD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-2922
Practice Address - Country:US
Practice Address - Phone:316-788-5533
Practice Address - Fax:316-788-7432
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-01684183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician