Healthcare Provider Details

I. General information

NPI: 1285899534
Provider Name (Legal Business Name): KATHLEEN A. FUMANDO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHLEEN A BENNETT PA-C

II. Dates (important events)

Enumeration Date: 07/25/2008
Last Update Date: 01/06/2021
Certification Date: 01/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 JACK MARTIN BLVD
BRICK NJ
08724-7732
US

IV. Provider business mailing address

3600 ROUTE 66 FL 3
NEPTUNE NJ
07753-2645
US

V. Phone/Fax

Practice location:
  • Phone: 732-840-2200
  • Fax: 732-922-6026
Mailing address:
  • Phone: 732-807-0879
  • Fax: 201-751-1680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP00195200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: