Provider Demographics
NPI:1295042505
Name:DALTON, KATHY ANN (RN)
Entity Type:Individual
Prefix:MS
First Name:KATHY
Middle Name:ANN
Last Name:DALTON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 N GRANT ST
Mailing Address - Street 2:PO BOX 357
Mailing Address - City:MERRILL
Mailing Address - State:OR
Mailing Address - Zip Code:97633-0357
Mailing Address - Country:US
Mailing Address - Phone:541-798-1034
Mailing Address - Fax:
Practice Address - Street 1:205 N GRANT ST
Practice Address - Street 2:
Practice Address - City:MERRILL
Practice Address - State:OR
Practice Address - Zip Code:97633-0357
Practice Address - Country:US
Practice Address - Phone:541-798-1034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR084053883RN163W00000X, 163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR084053883RNOtherOREGON RN LICENSE NUMBER