Basic Information
Provider Information | |||||||||
NPI: | 1760639173 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MACE | ||||||||
FirstName: | KATHRYN | ||||||||
MiddleName: | ELIZABETH | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NPP, FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MOULTON | ||||||||
OtherFirstName: | KATHRYN | ||||||||
OtherMiddleName: | ELIZABETH | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 33 LEWIS RD STE 2 | ||||||||
Address2: |   | ||||||||
City: | BINGHAMTON | ||||||||
State: | NY | ||||||||
PostalCode: | 139051040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077298156 | ||||||||
FaxNumber: | 6077293982 | ||||||||
Practice Location | |||||||||
Address1: | 10-42 MITCHELL AVE | ||||||||
Address2: |   | ||||||||
City: | BINGHAMTON | ||||||||
State: | NY | ||||||||
PostalCode: | 139031617 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077622990 | ||||||||
FaxNumber: | 6077622639 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/27/2008 | ||||||||
LastUpdateDate: | 04/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F335573 | NY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | 401390 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | 0330F335573 | 05 | NY |   | MEDICAID |