Provider Demographics
NPI:1558719807
Name:THELEN, KATHRYN MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARIE
Last Name:THELEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:COSTANTINI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1000 E PARIS AVE SE STE 200
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8383
Mailing Address - Country:US
Mailing Address - Phone:616-685-3450
Mailing Address - Fax:616-685-3454
Practice Address - Street 1:1000 E PARIS AVE SE
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3691
Practice Address - Country:US
Practice Address - Phone:616-685-3450
Practice Address - Fax:616-685-3454
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007795363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant