Provider Demographics
NPI:1669921730
Name:AULT, KATHRYN (CNM APRN)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:AULT
Suffix:
Gender:F
Credentials:CNM APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-7032
Mailing Address - Country:US
Mailing Address - Phone:907-435-0555
Mailing Address - Fax:844-274-6970
Practice Address - Street 1:205 W FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7032
Practice Address - Country:US
Practice Address - Phone:907-435-0555
Practice Address - Fax:844-274-6970
Is Sole Proprietor?:No
Enumeration Date:2016-09-29
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK115061363L00000X, 176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1702227Medicaid
AK1655161Medicaid