Provider Demographics
NPI:1508908575
Name:ROBERTSON, KATHLEEN (PHN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3057 BRIW RD
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-5321
Mailing Address - Country:US
Mailing Address - Phone:530-642-7126
Mailing Address - Fax:
Practice Address - Street 1:3057 BRIW RD
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-5321
Practice Address - Country:US
Practice Address - Phone:530-642-7126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA504561364SC1501X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SC1501XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCommunity Health/Public Health