Provider Demographics
NPI:1215497631
Name:VILLAREVIA, KATHRYN (FNP)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:VILLAREVIA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3073 WHITE MOUNTAIN HWY
Mailing Address - Street 2:
Mailing Address - City:NORTH CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03860-7101
Mailing Address - Country:US
Mailing Address - Phone:603-356-5461
Mailing Address - Fax:
Practice Address - Street 1:3073 WHITE MOUNTAIN HWY
Practice Address - Street 2:
Practice Address - City:NORTH CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03860
Practice Address - Country:US
Practice Address - Phone:603-356-5461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX140108363LF0000X
TXAP140108363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily