Provider Demographics
NPI:1679678825
Name:BAKER, KATHLEEN G (CRNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:G
Last Name:BAKER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CONVENTION AVE
Mailing Address - Street 2:4 PENN TOWER
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4311
Mailing Address - Country:US
Mailing Address - Phone:215-662-6488
Mailing Address - Fax:
Practice Address - Street 1:1 CONVENTION AVE
Practice Address - Street 2:4 PENN TOWER
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4311
Practice Address - Country:US
Practice Address - Phone:215-662-6488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP003068C363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI440771OtherMLHC MEDICARE AA
RI440771OtherMLHC MEDICARE AA
PAQ56321Medicare UPIN