Provider Demographics
NPI:1891736013
Name:PROVANZANA, KATHLEEN MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MICHELLE
Last Name:PROVANZANA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 LEXINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-1047
Mailing Address - Country:US
Mailing Address - Phone:740-363-9021
Mailing Address - Fax:740-363-7962
Practice Address - Street 1:6 LEXINGTON BLVD
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-1047
Practice Address - Country:US
Practice Address - Phone:740-363-3305
Practice Address - Fax:740-383-7942
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35071152P207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2025334OtherAETNA
311098079OtherTAX ID PHYS AND NON PHYS
311098079OtherTAX ID #
311098079240OtherCIGNA
0104351OtherUHC
080122321OtherTRAVELERS MEDICARE
OH2074133Medicaid
0855442OtherPALMETTO MEDICARE
353077OtherSUBMITTER NO.
311098079OtherTAX ID #
G78327Medicare UPIN
OH0855442Medicare ID - Type Unspecified