Provider Demographics
NPI:1376191312
Name:TEMBROCK, KATHLEEN DEVERA (AC-CPNP, MSN, CCRN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:DEVERA
Last Name:TEMBROCK
Suffix:
Gender:F
Credentials:AC-CPNP, MSN, CCRN
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:KAYE
Other - Last Name:DEVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN, CCRN
Mailing Address - Street 1:3455 SW US VETERANS HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3076
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1935 MEDICAL DISTRICT DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7701
Practice Address - Country:US
Practice Address - Phone:214-740-6177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201709498RN163WP0200X
TX1021237363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WP0200XNursing Service ProvidersRegistered NursePediatrics