Provider Demographics
NPI:1184161077
Name:KPAKA, BERNADETTE MAKULA
Entity type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:MAKULA
Last Name:KPAKA
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 1:948 CROSS COUNTRY DR W
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-3580
Mailing Address - Country:US
Mailing Address - Phone:856-669-4799
Mailing Address - Fax:
Practice Address - Street 1:948 CROSS COUNTRY DR W
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-3580
Practice Address - Country:US
Practice Address - Phone:856-669-4799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0200408Medicaid