Provider Demographics
NPI:1306123757
Name:CARLSON, KATHERINE I (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:I
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KATHERINE
Other - Middle Name:I
Other - Last Name:STELTENPOHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9951 ROCK CUT XING
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-1999
Mailing Address - Country:US
Mailing Address - Phone:815-639-8450
Mailing Address - Fax:815-639-8451
Practice Address - Street 1:9951 ROCK CUT XING
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-1999
Practice Address - Country:US
Practice Address - Phone:815-639-8450
Practice Address - Fax:815-639-8451
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-14
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-004178363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant