Healthcare Provider Details

I. General information

NPI: 1992138549
Provider Name (Legal Business Name): KATHLEEN MENOLD NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2013
Last Update Date: 10/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 WHITEHORSE MERCERVILLE RD SUITE 103
HAMILTON NJ
08619-3834
US

IV. Provider business mailing address

PO BOX 8500-2946
PHILADELPHIA PA
19178-2946
US

V. Phone/Fax

Practice location:
  • Phone: 609-587-6661
  • Fax: 609-587-8503
Mailing address:
  • Phone: 609-815-7810
  • Fax: 609-815-7814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number26NR06630900
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NR06630900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: