Provider Demographics
NPI:1295518363
Name:CLIFFORD, KATRINA MARIE
Entity type:Individual
Prefix:MRS
First Name:KATRINA
Middle Name:MARIE
Last Name:CLIFFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KATRINA
Other - Middle Name:MARIE
Other - Last Name:THORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:634 MORRISON ST
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-1108
Mailing Address - Country:US
Mailing Address - Phone:646-761-4542
Mailing Address - Fax:
Practice Address - Street 1:99 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-3537
Practice Address - Country:US
Practice Address - Phone:516-317-9284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1733079231174400000X
NY1733062231174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist