Provider Demographics
NPI:1801453105
Name:PROCTOR-VELEZ, KATIE ANN-MARIE
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:ANN-MARIE
Last Name:PROCTOR-VELEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:ANN-MARIE
Other - Last Name:PROCTOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:4850 W SWAMP RD
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:NY
Mailing Address - Zip Code:14561-9735
Mailing Address - Country:US
Mailing Address - Phone:585-857-1094
Mailing Address - Fax:585-526-5919
Practice Address - Street 1:4850 W SWAMP RD
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:NY
Practice Address - Zip Code:14561-9735
Practice Address - Country:US
Practice Address - Phone:585-857-1094
Practice Address - Fax:585-526-5919
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY330917164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY330917OtherNEW YORK STATE