Healthcare Provider Details

I. General information

NPI: 1164760807
Provider Name (Legal Business Name): KATHLEEN ANNE CAMPOS-GATJENS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2013
Last Update Date: 08/06/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 CLOVE RD
STATEN ISLAND NY
10301-3627
US

IV. Provider business mailing address

55 WATER ST FL 12
NEW YORK NY
10041-0004
US

V. Phone/Fax

Practice location:
  • Phone: 718-816-6440
  • Fax:
Mailing address:
  • Phone: 646-680-2888
  • Fax: 516-542-5556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number336710
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: