Provider Demographics
NPI:1023443058
Name:COLE-BOTTOMLEY, KATRINA A (RN)
Entity type:Individual
Prefix:MISS
First Name:KATRINA
Middle Name:A
Last Name:COLE-BOTTOMLEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:A
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:61 BULLVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:NY
Mailing Address - Zip Code:12549-1813
Mailing Address - Country:US
Mailing Address - Phone:845-741-5866
Mailing Address - Fax:
Practice Address - Street 1:61 BULLVILLE RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:NY
Practice Address - Zip Code:12549-1813
Practice Address - Country:US
Practice Address - Phone:845-741-5866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-10
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10315205164W00000X
NY755357-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY182320320Medicaid