Provider Demographics
NPI:1629180161
Name:CARLSON, KATHLEEN (NP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 VALPREDA RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-2973
Mailing Address - Country:US
Mailing Address - Phone:760-736-6780
Mailing Address - Fax:
Practice Address - Street 1:150 VALPREDA RD
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-2973
Practice Address - Country:US
Practice Address - Phone:460-736-6780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704178248363LF0000X
MI4704 178248363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI3233086Medicare PIN
MIMI3233127Medicare PIN