Provider Demographics
NPI:1194189019
Name:GANT, KATHLEEN A (CPNP-PC)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:A
Last Name:GANT
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:WISE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNP
Mailing Address - Street 1:4829 STREET ROAD
Mailing Address - Street 2:
Mailing Address - City:TREVOSE
Mailing Address - State:PA
Mailing Address - Zip Code:19053
Mailing Address - Country:US
Mailing Address - Phone:215-364-5800
Mailing Address - Fax:215-364-5899
Practice Address - Street 1:4829 STREET RD
Practice Address - Street 2:
Practice Address - City:TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053
Practice Address - Country:US
Practice Address - Phone:215-364-5800
Practice Address - Fax:215-364-5899
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP016050363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics