Provider Demographics
NPI:1891706628
Name:O'DONNELL, KATHERINE (FNP)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:O'DONNELL-ROSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4647 MEDICAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229
Mailing Address - Country:US
Mailing Address - Phone:210-592-0230
Mailing Address - Fax:210-592-0518
Practice Address - Street 1:4647 MEDICAL DRIVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229
Practice Address - Country:US
Practice Address - Phone:210-592-0230
Practice Address - Fax:210-592-0518
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX611505363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX171470101Medicaid
TX67000OtherCIDC
TX171470101Medicaid
TX8L11166Medicare PIN