Healthcare Provider Details

I. General information

NPI: 1689142143
Provider Name (Legal Business Name): KATHERINE OLMEDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2018
Last Update Date: 06/20/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

998 CROOKED HILL RD
WEST BRENTWOOD NY
11717-1019
US

IV. Provider business mailing address

105-07 HOWELLS RD APT G2
BAY SHORE NY
11706-2409
US

V. Phone/Fax

Practice location:
  • Phone: 631-761-3500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number883454
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number332702
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: