Provider Demographics
NPI:1023616331
Name:WELLENBERGER, KATHLEEN (RN)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:WELLENBERGER
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 1:421 VANDERBILT LOOP
Mailing Address - Street 2:
Mailing Address - City:YAPHANK
Mailing Address - State:NY
Mailing Address - Zip Code:11980-2049
Mailing Address - Country:US
Mailing Address - Phone:631-374-7827
Mailing Address - Fax:
Practice Address - Street 1:55 W AMES CT
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-2304
Practice Address - Country:US
Practice Address - Phone:516-822-6111
Practice Address - Fax:516-348-0288
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY271171163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse