Provider Demographics
NPI:1982927430
Name:MISTRETTA, KATHY JO (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:JO
Last Name:MISTRETTA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4390 YORK RD
Mailing Address - Street 2:
Mailing Address - City:LEICESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14481-9706
Mailing Address - Country:US
Mailing Address - Phone:585-481-0904
Mailing Address - Fax:
Practice Address - Street 1:6620 EAST BETHANY LEROY RD
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:NY
Practice Address - Zip Code:14143-9565
Practice Address - Country:US
Practice Address - Phone:585-768-4646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-11
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY253381-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse