MEDICARE: KETTLENE CASIMIR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	698868-1	NY
2	164W00000X	Licensed Practical Nurse	310891	NY

General Provider Information

NPI Number	:	1053740167
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KETTLENE CASIMIR

Provider Business Mailing Address
First Line	:	1241 FULTON AVE
Second Line	:	2ND FLOOR
City	:	BRONX
State	:	NY
Zip	:	10456-3401
Country	:	US
Telephone Number	:	774-268-0410
Fax Number	:

Provider Business Practice Location Address
First Line	:	1241 FULTON AVE
Second Line	:	2ND FLOOR
City	:	BRONX
State	:	NY
Zip	:	10456-3401
Country	:	US
Telephone Number	:	774-268-0410
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2013
Last Update Date	:	11/23/2015

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Directions to “ KETTLENE CASIMIR ” Practice Location

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