Provider Demographics
NPI:1699080606
Name:KALKHOF, MARY DIANE (LPN)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:DIANE
Last Name:KALKHOF
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:DIANE
Other - Last Name:KALKHOF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:5 RUSSELL CT
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-4013
Mailing Address - Country:US
Mailing Address - Phone:631-475-7831
Mailing Address - Fax:
Practice Address - Street 1:5 RUSSELL CT
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-4013
Practice Address - Country:US
Practice Address - Phone:631-475-7831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY237551-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse