Provider Demographics
NPI:1184891376
Name:STUDDERT, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:STUDDERT
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 1:3632 OVERLOOK AVE
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:10598-1018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3632 OVERLOOK AVE
Practice Address - Street 2:
Practice Address - City:YORKTOWN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:10598-1018
Practice Address - Country:US
Practice Address - Phone:914-962-1377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4013701163W00000X, 163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02909800Medicaid