Provider Demographics
NPI:1104244599
Name:STAGE, KATHARINE
Entity type:Individual
Prefix:
First Name:KATHARINE
Middle Name:
Last Name:STAGE
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 1:82 QUEEN DR
Mailing Address - Street 2:
Mailing Address - City:SOUND BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11789-1528
Mailing Address - Country:US
Mailing Address - Phone:631-849-1507
Mailing Address - Fax:631-849-1507
Practice Address - Street 1:82 QUEEN DR
Practice Address - Street 2:
Practice Address - City:SOUND BEACH
Practice Address - State:NY
Practice Address - Zip Code:11789-1528
Practice Address - Country:US
Practice Address - Phone:631-849-1507
Practice Address - Fax:631-849-1507
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307230-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse