Provider Demographics
NPI:1275819641
Name:MOTT, KATHLEEN A (NP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:MOTT
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 1:121 SOTOYOME ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4823
Mailing Address - Country:US
Mailing Address - Phone:707-525-6180
Mailing Address - Fax:707-521-3854
Practice Address - Street 1:121 SOTOYOME ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4823
Practice Address - Country:US
Practice Address - Phone:707-525-6180
Practice Address - Fax:707-521-3854
Is Sole Proprietor?:No
Enumeration Date:2011-10-28
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN321979363L00000X
CA4267364SW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SW0102XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistWomen's Health