Provider Demographics
NPI:1487088704
Name:DISTIN, KATHLEEN ELIZABETH (RN, IBCLC)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:ELIZABETH
Last Name:DISTIN
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:MRS
Other - First Name:KATHLEEN
Other - Middle Name:ELIZABETH
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:110 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-2507
Mailing Address - Country:US
Mailing Address - Phone:315-349-5572
Mailing Address - Fax:315-349-5701
Practice Address - Street 1:110 W 6TH ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2507
Practice Address - Country:US
Practice Address - Phone:315-349-5572
Practice Address - Fax:315-349-5701
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY429531163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant