Provider Demographics
NPI:1114057510
Name:BOOTH, KATHLEEN MARIE (RNC, NP)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:BOOTH
Suffix:
Gender:F
Credentials:RNC, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7 RED PINE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH OAKS
Mailing Address - State:MN
Mailing Address - Zip Code:55127-2030
Mailing Address - Country:US
Mailing Address - Phone:651-490-7863
Mailing Address - Fax:651-490-7863
Practice Address - Street 1:2115 SUMMIT AVE
Practice Address - Street 2:STUDENT HEALTH SERVICES # 5056
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105
Practice Address - Country:US
Practice Address - Phone:651-962-6750
Practice Address - Fax:651-962-6751
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1226809363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNS55808Medicare UPIN