Basic Information
Provider Information | |||||||||
NPI: | 1609901594 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GREENFIELD | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 367 S. GULPH RD | ||||||||
Address2: | ATT IPM CREDENTIALING | ||||||||
City: | KING OF PRUSSIA | ||||||||
State: | PA | ||||||||
PostalCode: | 194063121 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7753569393 | ||||||||
FaxNumber: | 7753565590 | ||||||||
Practice Location | |||||||||
Address1: | 606 4TH AVE W | ||||||||
Address2: |   | ||||||||
City: | PALMETTO | ||||||||
State: | FL | ||||||||
PostalCode: | 342215226 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9417227785 | ||||||||
FaxNumber: | 9417295267 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/22/2007 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA2662 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA2662 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 011158700 | 05 | FL |   | MEDICAID | YOE4G | 01 | FL | BCBS | OTHER |