Provider Demographics
NPI:1902051030
Name:KOONS, KATHRYN MARY (CRNP)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARY
Last Name:KOONS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:MARY
Other - Last Name:DEBORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:13121 BROOK LANE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742
Mailing Address - Country:US
Mailing Address - Phone:301-733-0330
Mailing Address - Fax:301-733-4038
Practice Address - Street 1:18714 N VILLAGE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-2454
Practice Address - Country:US
Practice Address - Phone:301-733-0330
Practice Address - Fax:301-733-4038
Is Sole Proprietor?:No
Enumeration Date:2008-11-17
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR212570363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDHE02Medicare PIN
WVWV4190AMedicare UPIN
IL0533210001Medicare NSC
IL407270006Medicare PIN