Provider Demographics
NPI:1053097691
Name:CALLAGHAN, KATHLEEN T (NP, RN)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:T
Last Name:CALLAGHAN
Suffix:
Gender:F
Credentials:NP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-1724
Mailing Address - Country:US
Mailing Address - Phone:631-697-1517
Mailing Address - Fax:
Practice Address - Street 1:45 RESEARCH WAY STE 108
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-6401
Practice Address - Country:US
Practice Address - Phone:631-941-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY757006-01163W00000X
NYF311294-01363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse