Healthcare Provider Details

I. General information

NPI: 1619463890
Provider Name (Legal Business Name): KATRINA IM PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2018
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 CROSS RIVER RD
KATONAH NY
10536
US

IV. Provider business mailing address

800 CROSS RIVER RD
KATONAH NY
10536-3549
US

V. Phone/Fax

Practice location:
  • Phone: 516-578-1246
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number402462
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number746849
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: