Provider Demographics
NPI:1376546200
Name:HALVERSON, KATHLEEN JANE (CNP)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:JANE
Last Name:HALVERSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:826 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IN
Mailing Address - Zip Code:47960-1752
Mailing Address - Country:US
Mailing Address - Phone:574-583-3333
Mailing Address - Fax:574-583-2896
Practice Address - Street 1:826 N 6TH ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IN
Practice Address - Zip Code:47960-1752
Practice Address - Country:US
Practice Address - Phone:574-583-3333
Practice Address - Fax:574-583-2896
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000299A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000335832OtherANTHEM BLUE CROSS
1540739OtherUNITED MINEWORKERS
5531418OtherAETNA
500002653OtherRAILROAD MEDICARE
IN200121420Medicaid
1540739OtherUNITED MINEWORKERS
5531418OtherAETNA