Healthcare Provider Details

I. General information

NPI: 1013061621
Provider Name (Legal Business Name): KATY KITTERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 N WOODLAWN BLVD
DERBY KS
67037-2922
US

IV. Provider business mailing address

1412 N WOODLAWN BLVD
DERBY KS
67037-2922
US

V. Phone/Fax

Practice location:
  • Phone: 316-788-5533
  • Fax: 316-788-7432
Mailing address:
  • Phone: 316-788-5533
  • Fax: 316-788-7432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number14-01684
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: