Provider Demographics
NPI:1275622417
Name:SHANTZ, KATHRYN MARIE (CNM)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARIE
Last Name:SHANTZ
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60728 COUNTY ROAD 27
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46528-6638
Mailing Address - Country:US
Mailing Address - Phone:574-534-5315
Mailing Address - Fax:574-534-5315
Practice Address - Street 1:60728 COUNTY ROAD 27
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-6638
Practice Address - Country:US
Practice Address - Phone:574-535-3501
Practice Address - Fax:260-768-7765
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN72000098A367A00000X
MI4704219087367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife