Provider Demographics
NPI:1760439574
Name:RODMAN, KATHLEEN CONNOLE (APRN)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:CONNOLE
Last Name:RODMAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 DOUGLAS ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2610
Mailing Address - Country:US
Mailing Address - Phone:801-583-9639
Mailing Address - Fax:
Practice Address - Street 1:508 E SOUTH TEMPLE
Practice Address - Street 2:STE 205
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1013
Practice Address - Country:US
Practice Address - Phone:801-596-0100
Practice Address - Fax:801-596-8800
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT193462-4405363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107019359102OtherSELECT HEALTH
87-0528056OtherTIN
UT000062012Medicare PIN
UT107019359102OtherSELECT HEALTH