Provider Demographics
NPI:1538383195
Name:PERNICE, KATHRYN M (NP)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:M
Last Name:PERNICE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 INTERLOCHEN PKWY
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-1223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:375 ROUTE 32
Practice Address - Street 2:
Practice Address - City:CENTRAL VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10917-3201
Practice Address - Country:US
Practice Address - Phone:845-928-8185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF4201841363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP28482Medicare UPIN