Provider Demographics
NPI:1063072775
Name:PROPHETE, KATHIANA
Entity type:Individual
Prefix:
First Name:KATHIANA
Middle Name:
Last Name:PROPHETE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1167 E JERSEY ST APT 3R
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07201-2374
Mailing Address - Country:US
Mailing Address - Phone:908-838-1692
Mailing Address - Fax:
Practice Address - Street 1:1933 SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-3416
Practice Address - Country:US
Practice Address - Phone:908-838-1693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT01186900225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ824620009Medicaid