Provider Demographics
NPI:1053323543
Name:PROVENCHER, KATHLEEN (NP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:PROVENCHER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2521 BREAUX TRCE
Mailing Address - Street 2:
Mailing Address - City:SEABROOK
Mailing Address - State:TX
Mailing Address - Zip Code:77586-3397
Mailing Address - Country:US
Mailing Address - Phone:281-532-2118
Mailing Address - Fax:
Practice Address - Street 1:4545 POST OAK PLACE DR
Practice Address - Street 2:SUITE 130
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-3164
Practice Address - Country:US
Practice Address - Phone:713-960-8008
Practice Address - Fax:713-960-0965
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX636908363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care