Provider Demographics
NPI:1427298611
Name:MERRY, KATHLEEN L (RN)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:L
Last Name:MERRY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:KAYENTA
Mailing Address - State:AZ
Mailing Address - Zip Code:86033-0368
Mailing Address - Country:US
Mailing Address - Phone:928-672-3000
Mailing Address - Fax:
Practice Address - Street 1:HIGHWAY 98 AND NAVAJO ROUTE 16
Practice Address - Street 2:
Practice Address - City:TONALEA
Practice Address - State:AZ
Practice Address - Zip Code:86044
Practice Address - Country:US
Practice Address - Phone:928-672-2983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-27
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN274405L372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ860719854Medicaid
AZ030073Medicare Oscar/Certification
AZHSZ045Medicare PIN