Provider Demographics
NPI:1306821160
Name:MERRY, KATHLEEN (ARNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MERRY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:
Other - Last Name:MERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ARNP
Mailing Address - Street 1:905 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50703-4407
Mailing Address - Country:US
Mailing Address - Phone:319-874-3000
Mailing Address - Fax:319-874-3411
Practice Address - Street 1:905 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-4407
Practice Address - Country:US
Practice Address - Phone:319-272-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAC-070768363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0076372Medicaid
IA17879OtherWELLMARK
IAP04231Medicare UPIN
IA17879OtherWELLMARK