Provider Demographics
NPI:1255340782
Name:VANDERBROOK, KATHLEEN MATTOON (NP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MATTOON
Last Name:VANDERBROOK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE
Mailing Address - Street 2:BOX 652
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-275-7741
Mailing Address - Fax:585-244-4320
Practice Address - Street 1:4 COULTER RD STE 1680
Practice Address - Street 2:
Practice Address - City:CLIFTON SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:14432-1122
Practice Address - Country:US
Practice Address - Phone:315-906-4059
Practice Address - Fax:315-906-4132
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYF300815363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01545275Medicaid
NY01545275Medicaid
NYJ400011777Medicare PIN