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General NPI Number Information
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NPI Number | 1083162838
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Entity Type | Individual
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Provider Name | KATHERINE BERENICE CAMPOVERDE AREVALO
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Gender | Female
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Dates
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Enumeration Date | 09/21/2016
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Last Update Date | 09/24/2019
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Provider Practice Location Address
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Address Line | 1157 BILLIGS CT SE AP# 1A
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City | GRAND RAPIDS
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State | MI
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Zip | 49508
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Country | US
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Telephone | 347-724-5845
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Fax |
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Provider Business Mailing Address
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Address Line | 9838 57TH AVE APT 2J
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City | CORONA
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State | NY
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Zip | 11368-4918
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Country | US
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Telephone | 347-724-5845
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 247200000X
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Taxonomy Name | Other Technician
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License Number | 524398310
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License Number State | NY
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