Healthcare Provider Details

I. General information

NPI: 1710121819
Provider Name (Legal Business Name): KATHLEEN GANUN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2009
Last Update Date: 04/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 UNION AVE
CENTER MORICHES NY
11934-3213
US

IV. Provider business mailing address

77 UNION AVE
CENTER MORICHES NY
11934-3213
US

V. Phone/Fax

Practice location:
  • Phone: 631-878-0795
  • Fax: 631-878-0527
Mailing address:
  • Phone: 631-878-0795
  • Fax: 631-878-0527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number26-2682906
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: