Provider Demographics
NPI:1285858092
Name:GAMMON, KATHY (RPT,PA)
Entity Type:Individual
Prefix:MS
First Name:KATHY
Middle Name:
Last Name:GAMMON
Suffix:
Gender:F
Credentials:RPT,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W 25TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-4527
Mailing Address - Country:US
Mailing Address - Phone:208-524-1550
Mailing Address - Fax:208-523-3148
Practice Address - Street 1:555 W 25TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-4527
Practice Address - Country:US
Practice Address - Phone:208-524-1550
Practice Address - Fax:208-523-3148
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT560174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist