Provider Demographics
NPI:1689269748
Name:NESSELRODE, KATHY LYNN (A-GNP)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:LYNN
Last Name:NESSELRODE
Suffix:
Gender:F
Credentials:A-GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3438 COUNTY ROAD 1626
Mailing Address - Street 2:
Mailing Address - City:AVINGER
Mailing Address - State:TX
Mailing Address - Zip Code:75630-3440
Mailing Address - Country:US
Mailing Address - Phone:903-665-0052
Mailing Address - Fax:
Practice Address - Street 1:3438 COUNTY ROAD 1626
Practice Address - Street 2:
Practice Address - City:AVINGER
Practice Address - State:TX
Practice Address - Zip Code:75630-3440
Practice Address - Country:US
Practice Address - Phone:903-665-0052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1029235363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner