Provider Demographics
NPI:1720694706
Name:MCNULTY, KATELYN ROSE (PMHNP)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:ROSE
Last Name:MCNULTY
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3229 EAGLE PASS
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40213-1274
Mailing Address - Country:US
Mailing Address - Phone:270-316-5655
Mailing Address - Fax:
Practice Address - Street 1:110 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4116
Practice Address - Country:US
Practice Address - Phone:212-369-6757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY58001363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health