Healthcare Provider Details

I. General information

NPI: 1578054367
Provider Name (Legal Business Name): KATHLEEN WILLIS-FARMER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 06/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10590 ENDURING FREEDOM DRIVE
FORT DRUM NY
13602
US

IV. Provider business mailing address

10590 ENDURING FREEDOM DRIVE
FORT DRUM NY
13602-5005
US

V. Phone/Fax

Practice location:
  • Phone: 315-772-6234
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number19916
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: