=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215122908
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. KATHLEEN CALMA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2007
-----------------------------------------------------
Last Update Date | 09/06/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14 MANCHESTER LN
-----------------------------------------------------
City | STONY BROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11790-2804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-689-2383
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35 IMPERIAL DR
-----------------------------------------------------
City | SELDEN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11784-1720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-846-4342
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 5574366
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------