Provider Demographics
NPI:1275892093
Name:BOOZER, KATHILEEN RILEY (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:KATHILEEN
Middle Name:RILEY
Last Name:BOOZER
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 RANCHO HERMOSO
Mailing Address - Street 2:
Mailing Address - City:LORENA
Mailing Address - State:TX
Mailing Address - Zip Code:76655-0015
Mailing Address - Country:US
Mailing Address - Phone:728-351-8679
Mailing Address - Fax:
Practice Address - Street 1:7125 NEW SANGER AVE STE 502
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-4054
Practice Address - Country:US
Practice Address - Phone:972-835-1867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-14
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QH0100X
TX762114363L00000X
TXAP121522363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111521403Medicaid