Provider Demographics
NPI:1861945735
Name:FORD, KATHLEEN M
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:FORD
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 1:558 OAKHOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:LANOKA HARBOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08734-2130
Mailing Address - Country:US
Mailing Address - Phone:610-733-0559
Mailing Address - Fax:
Practice Address - Street 1:140 E RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-3917
Practice Address - Country:US
Practice Address - Phone:615-610-7705
Practice Address - Fax:833-464-4086
Is Sole Proprietor?:No
Enumeration Date:2016-07-27
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP0616362363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health