Provider Demographics
NPI:1568679603
Name:MARSHALL, KATHLEEN BRIDGET (CPNP)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:BRIDGET
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9530 W HEATHER RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-7232
Mailing Address - Country:US
Mailing Address - Phone:208-233-7699
Mailing Address - Fax:
Practice Address - Street 1:717 MISSION RD.
Practice Address - Street 2:
Practice Address - City:FORT HALL
Practice Address - State:ID
Practice Address - Zip Code:83203-0717
Practice Address - Country:US
Practice Address - Phone:208-238-5435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP433A363LP0200X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Not Answered363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8063500Medicaid
ID8064977Medicaid
ID80662922Medicaid