Healthcare Provider Details

I. General information

NPI: 1083162838
Provider Name (Legal Business Name): KATHERINE BERENICE CAMPOVERDE AREVALO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 09/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1157 BILLIGS CT SE AP# 1A
GRAND RAPIDS MI
49508
US

IV. Provider business mailing address

9838 57TH AVE APT 2J
CORONA NY
11368-4918
US

V. Phone/Fax

Practice location:
  • Phone: 347-724-5845
  • Fax:
Mailing address:
  • Phone: 347-724-5845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number524398310
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: