Provider Demographics
NPI:1578755732
Name:DEWALD, KATHLEEN S (ARNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:S
Last Name:DEWALD
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 PLEASANT ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1406
Mailing Address - Country:US
Mailing Address - Phone:515-241-5750
Mailing Address - Fax:515-241-5757
Practice Address - Street 1:1200 PLEASANT ST
Practice Address - Street 2:SUITE 206
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1406
Practice Address - Country:US
Practice Address - Phone:515-241-5750
Practice Address - Fax:515-241-5757
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IAA076050363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP01041571OtherRR MEDICARE
IA1578755732Medicaid
IA1578755732Medicaid