Provider Demographics
NPI:1972054997
Name:MILLARD, KATHY MOORE (RN)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:MOORE
Last Name:MILLARD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7550 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:LOWVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13367-1574
Mailing Address - Country:US
Mailing Address - Phone:315-376-5450
Mailing Address - Fax:315-376-7221
Practice Address - Street 1:482 BLACK RIVER PKWY
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2416
Practice Address - Country:US
Practice Address - Phone:315-782-1777
Practice Address - Fax:315-785-8628
Is Sole Proprietor?:No
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY533385163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse