Provider Demographics
NPI:1508962598
Name:RODOSEVICH, KATHLEEN L (CRNA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:L
Last Name:RODOSEVICH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 NE CERYSA LN
Mailing Address - Street 2:
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-8226
Mailing Address - Country:US
Mailing Address - Phone:541-447-8131
Mailing Address - Fax:
Practice Address - Street 1:400 9TH ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-7398
Practice Address - Country:US
Practice Address - Phone:541-997-7134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered