Provider Demographics
NPI:1427441153
Name:STAUDER, KATHRYN R (AGACNP-BC)
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:R
Last Name:STAUDER
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:MRS
Other - First Name:KATHRYN
Other - Middle Name:R
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:310 EAST SHORE ROAD
Mailing Address - Street 2:SUITE #104
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11023
Mailing Address - Country:US
Mailing Address - Phone:516-829-9550
Mailing Address - Fax:516-829-9718
Practice Address - Street 1:310 EAST SHORE ROAD
Practice Address - Street 2:SUITE #104
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11023
Practice Address - Country:US
Practice Address - Phone:516-829-9550
Practice Address - Fax:516-829-9718
Is Sole Proprietor?:No
Enumeration Date:2015-03-04
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY430847363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care