Provider Demographics
NPI:1982291548
Name:RICHARDSON, KATONDRA RAESHEL
Entity Type:Individual
Prefix:
First Name:KATONDRA
Middle Name:RAESHEL
Last Name:RICHARDSON
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 1:550 NEWTON ST APT A
Mailing Address - Street 2:
Mailing Address - City:KEYSER
Mailing Address - State:WV
Mailing Address - Zip Code:26726-1568
Mailing Address - Country:US
Mailing Address - Phone:304-813-2403
Mailing Address - Fax:
Practice Address - Street 1:550 NEWTON ST APT A
Practice Address - Street 2:
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726-1568
Practice Address - Country:US
Practice Address - Phone:304-813-2403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant