Provider Demographics
NPI:1801100201
Name:WIRTZ, KATHLEEN ANNE (ARNP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANNE
Last Name:WIRTZ
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 48
Mailing Address - Street 2:
Mailing Address - City:CARROLLS
Mailing Address - State:WA
Mailing Address - Zip Code:98609-0048
Mailing Address - Country:US
Mailing Address - Phone:360-749-0010
Mailing Address - Fax:360-425-0861
Practice Address - Street 1:1655 HUDSON ST STE 1
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2949
Practice Address - Country:US
Practice Address - Phone:360-749-0010
Practice Address - Fax:844-654-7171
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-28
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60184972363LW0102X
WAAP60172230367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health