Provider Demographics
NPI:1255952529
Name:BRAINERD, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:BRAINERD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:MIKULAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5325 FARAON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3488
Mailing Address - Country:US
Mailing Address - Phone:816-271-6350
Mailing Address - Fax:816-271-6753
Practice Address - Street 1:5325 FARAON ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3488
Practice Address - Country:US
Practice Address - Phone:816-271-6350
Practice Address - Fax:816-271-6753
Is Sole Proprietor?:No
Enumeration Date:2020-04-28
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
MO2024019268367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No374U00000XNursing Service Related ProvidersHome Health Aide