Provider Demographics
NPI:1740836089
Name:MIGNONE, KATHLEEN N
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:N
Last Name:MIGNONE
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 1:812 LEHIGH AVE
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-3805
Mailing Address - Country:US
Mailing Address - Phone:607-240-8053
Mailing Address - Fax:
Practice Address - Street 1:30 W STATE ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-2357
Practice Address - Country:US
Practice Address - Phone:607-723-7308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY721829363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health