Provider Demographics
NPI:1649885336
Name:KOLB, KAITLIN ROSE
Entity type:Individual
Prefix:MRS
First Name:KAITLIN
Middle Name:ROSE
Last Name:KOLB
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 1:269-01 76TH AVE
Mailing Address - Street 2:RM CH 222
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:269-01 76TH AVE
Practice Address - Street 2:RM CH 222
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040
Practice Address - Country:US
Practice Address - Phone:516-470-3422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY383170363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics