Provider Demographics
NPI:1023092921
Name:WOLVERTON, KATHY MARIE (CRNA)
Entity type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:MARIE
Last Name:WOLVERTON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 COUNTRY CIR
Mailing Address - Street 2:
Mailing Address - City:ADVANCE
Mailing Address - State:NC
Mailing Address - Zip Code:27006-7456
Mailing Address - Country:US
Mailing Address - Phone:336-998-7590
Mailing Address - Fax:
Practice Address - Street 1:111 COUNTRY CIR
Practice Address - Street 2:
Practice Address - City:ADVANCE
Practice Address - State:NC
Practice Address - Zip Code:27006-7456
Practice Address - Country:US
Practice Address - Phone:336-998-7590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC075728367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2612582Medicare PIN