Provider Demographics
NPI:1124785019
Name:GABAT, KIETHLYN (CRNP)
Entity type:Individual
Prefix:
First Name:KIETHLYN
Middle Name:
Last Name:GABAT
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 RYAN DR
Mailing Address - Street 2:
Mailing Address - City:RISING SUN
Mailing Address - State:MD
Mailing Address - Zip Code:21911-1841
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 RYAN DR
Practice Address - Street 2:
Practice Address - City:RISING SUN
Practice Address - State:MD
Practice Address - Zip Code:21911-1841
Practice Address - Country:US
Practice Address - Phone:410-642-9172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-26
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR202095363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG-130-469-095-025Medicaid