Provider Demographics
NPI:1487728622
Name:OLDFATHER, KATHLEEN A (NP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:OLDFATHER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1477 W COMMERCE CT
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85746-6016
Mailing Address - Country:US
Mailing Address - Phone:207-923-2935
Mailing Address - Fax:
Practice Address - Street 1:8050 E LAKESIDE PKWY
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85730-1254
Practice Address - Country:US
Practice Address - Phone:520-792-3293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN 033432363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ621765Medicaid
AZAP3272OtherLICENSE