Provider Demographics
NPI:1538802830
Name:LACASSE, KATHLEEN L (IDMT)
Entity type:Individual
Prefix:MISS
First Name:KATHLEEN
Middle Name:L
Last Name:LACASSE
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:90 HOPE DRIVE BLDG 6000
Mailing Address - Street 2:
Mailing Address - City:MOUNTIAN HOME AFB
Mailing Address - State:ID
Mailing Address - Zip Code:83648
Mailing Address - Country:US
Mailing Address - Phone:860-921-6527
Mailing Address - Fax:
Practice Address - Street 1:90 HOPE DRIVE BLDG 6000
Practice Address - Street 2:
Practice Address - City:MOUNTIAN HOME AFB
Practice Address - State:ID
Practice Address - Zip Code:83648
Practice Address - Country:US
Practice Address - Phone:208-828-7401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-15
Last Update Date:2023-06-26
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians