=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033888995
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHRYN KLAMMER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2021
-----------------------------------------------------
Last Update Date | 09/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11915 ROCKAWAY BEACH BLVD
-----------------------------------------------------
City | ROCKAWAY PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11694-1970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-634-3211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 RUSSEK DR
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10312-1628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-354-3483
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 012049
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------