Provider Demographics
NPI:1215115886
Name:DOUGLAS, KATHLEEN MARIE
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:DOUGLAS
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 1:145 SCHOOL ST.
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05767-0184
Mailing Address - Country:US
Mailing Address - Phone:802-767-3332
Mailing Address - Fax:
Practice Address - Street 1:145 SCHOOL ST.
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05767-0184
Practice Address - Country:US
Practice Address - Phone:802-767-3332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR083751163WE0003X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WE0003XNursing Service ProvidersRegistered NurseEmergency