Provider Demographics
NPI:1861157935
Name:POLIDORO, KACIE (RN)
Entity type:Individual
Prefix:
First Name:KACIE
Middle Name:
Last Name:POLIDORO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 NEW RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08088-1403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:343 NEW RD
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NJ
Practice Address - Zip Code:08088-1403
Practice Address - Country:US
Practice Address - Phone:609-351-8139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NO11015000163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse