Provider Demographics
NPI:1982255543
Name:HART, KATHRYN ROSE
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ROSE
Last Name:HART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 MAIN ST APT 263
Mailing Address - Street 2:
Mailing Address - City:PHILOMATH
Mailing Address - State:OR
Mailing Address - Zip Code:97370-2162
Mailing Address - Country:US
Mailing Address - Phone:541-231-8282
Mailing Address - Fax:
Practice Address - Street 1:601 SW 2ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-3199
Practice Address - Country:US
Practice Address - Phone:503-265-4727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-25
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000004338172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker