Provider Demographics
NPI:1386707305
Name:CRAIN, KATHRYN SUE (MED)
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:SUE
Last Name:CRAIN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1885 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-5559
Mailing Address - Country:US
Mailing Address - Phone:928-782-6172
Mailing Address - Fax:
Practice Address - Street 1:1885 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-5559
Practice Address - Country:US
Practice Address - Phone:928-782-6172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10454385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ968828Medicaid