Provider Demographics
NPI:1285626390
Name:GRADOVILLE, KATHLEEN (ARNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:GRADOVILLE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:EVOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1212 PLEASANT ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1453
Mailing Address - Country:US
Mailing Address - Phone:515-241-6548
Mailing Address - Fax:515-241-8789
Practice Address - Street 1:1212 PLEASANT ST
Practice Address - Street 2:SUITE 204
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1453
Practice Address - Country:US
Practice Address - Phone:515-241-6548
Practice Address - Fax:515-241-8789
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAC81143363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1285626390Medicaid
IA17515013OtherMEDICARE
IA1285626390Medicaid
MO1285626390Medicaid