Basic Information
Provider Information | |||||||||
NPI: | 1265665616 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FARRELL HARRIS | ||||||||
FirstName: | KATHERINE | ||||||||
MiddleName: | C | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | R.D., C.D.N., C.D.E. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | ADVANTAGECARE PHYSICIANS, PC | ||||||||
Address2: | 55 WATER STREET 2ND FLOOR CRED DEPT | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100410004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6466802888 | ||||||||
FaxNumber: | 5165425556 | ||||||||
Practice Location | |||||||||
Address1: | 52 DUANE ST | ||||||||
Address2: |   | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100071207 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6466804227 | ||||||||
FaxNumber: | 5165425556 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/02/2009 | ||||||||
LastUpdateDate: | 09/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WD0400X | 20510119 | NY | N |   | Nursing Service Providers | Registered Nurse | Diabetes Educator | 133V00000X | 005474 | NY | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
ID Information
ID | Type | State | Issuer | Description | 03459592 | 05 | NY |   | MEDICAID | 000600027483 | 01 | NY | HEALTH PLUS | OTHER |