Provider Demographics
NPI:1447856026
Name:KO, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:KO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 HAYWOOD LN
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:NY
Mailing Address - Zip Code:12144-5833
Mailing Address - Country:US
Mailing Address - Phone:518-915-8855
Mailing Address - Fax:
Practice Address - Street 1:2982 US HIGHWAY 9
Practice Address - Street 2:
Practice Address - City:VALATIE
Practice Address - State:NY
Practice Address - Zip Code:12184-5411
Practice Address - Country:US
Practice Address - Phone:518-915-8855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY063092183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist