Provider Demographics
NPI:1285808626
Name:BOCKHOLD, KATHLEEN MARIE (MSN, ARNP-BC)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:BOCKHOLD
Suffix:
Gender:F
Credentials:MSN, ARNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:122 AIRWAYS PL
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-5872
Mailing Address - Country:US
Mailing Address - Phone:662-349-9990
Mailing Address - Fax:662-349-2620
Practice Address - Street 1:1365 W BRIERBROOK RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-2208
Practice Address - Country:US
Practice Address - Phone:662-349-9990
Practice Address - Fax:662-349-2620
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5965363LA2200X
MSA810342363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I505663Medicare PIN