Provider Demographics
NPI:1659478899
Name:RICHARDSON, KATHLEEN (ARNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:RICHARDSON
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 1:142 W RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-3637
Mailing Address - Country:US
Mailing Address - Phone:712-792-3141
Mailing Address - Fax:
Practice Address - Street 1:311 S CLARK ST
Practice Address - Street 2:
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401-3038
Practice Address - Country:US
Practice Address - Phone:712-792-3581
Practice Address - Fax:712-792-2124
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA77622363LP0200X
IAG 052035363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAG 052035OtherIOWA LICENSE