Provider Demographics
NPI:1528610144
Name:KITTLES, DORA MAE
Entity type:Individual
Prefix:
First Name:DORA
Middle Name:MAE
Last Name:KITTLES
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 1:62 E BOOKER AVE
Mailing Address - Street 2:
Mailing Address - City:WYANDANCH
Mailing Address - State:NY
Mailing Address - Zip Code:11798-4503
Mailing Address - Country:US
Mailing Address - Phone:631-306-6249
Mailing Address - Fax:
Practice Address - Street 1:62 E BOOKER AVE
Practice Address - Street 2:
Practice Address - City:WYANDANCH
Practice Address - State:NY
Practice Address - Zip Code:11798-4503
Practice Address - Country:US
Practice Address - Phone:631-306-6249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-13
Last Update Date:2019-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY335440164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse