Provider Demographics
NPI:1427649979
Name:BOGI, KATELYN PAIGE (NURSE)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:PAIGE
Last Name:BOGI
Suffix:
Gender:F
Credentials:NURSE
Other - Prefix:MRS
Other - First Name:KATELYN
Other - Middle Name:PAIGE
Other - Last Name:PICCOLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:240 LONG ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WYANDANCH
Mailing Address - State:NY
Mailing Address - Zip Code:11798-3123
Mailing Address - Country:US
Mailing Address - Phone:631-236-4325
Mailing Address - Fax:631-514-3026
Practice Address - Street 1:240 LONG ISLAND AVE
Practice Address - Street 2:
Practice Address - City:WYANDANCH
Practice Address - State:NY
Practice Address - Zip Code:11798-3123
Practice Address - Country:US
Practice Address - Phone:631-236-4325
Practice Address - Fax:631-514-3026
Is Sole Proprietor?:No
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY327870164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY328870Medicaid