Provider Demographics
NPI:1942273008
Name:WAYBRANT, KATHLEEN M (FNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:WAYBRANT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 W HARVARD AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-2754
Mailing Address - Country:US
Mailing Address - Phone:541-440-6390
Mailing Address - Fax:541-440-6392
Practice Address - Street 1:1813 W HARVARD AVE
Practice Address - Street 2:STE 201
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2754
Practice Address - Country:US
Practice Address - Phone:541-440-6390
Practice Address - Fax:541-440-6392
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR80045889N1207Q00000X
OR080045889N1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR168395Medicaid
R103163OtherMCR PART B
OR154971Medicaid
381846Medicare Oscar/Certification
107234Medicare PIN
R85895Medicare UPIN