Provider Demographics
NPI:1376534727
Name:COUSINS, KATHLEEN H (WHCNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:H
Last Name:COUSINS
Suffix:
Gender:F
Credentials:WHCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 MOUNT HOPE AVE
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4236
Mailing Address - Country:US
Mailing Address - Phone:207-947-0469
Mailing Address - Fax:207-941-1957
Practice Address - Street 1:336 MOUNT HOPE AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4236
Practice Address - Country:US
Practice Address - Phone:207-947-0469
Practice Address - Fax:207-941-1957
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER025001363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME411080099Medicaid