Provider Demographics
NPI:1730172107
Name:DOUGLAS, KATHY A (APRN-BC)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:A
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 GENN DR
Mailing Address - Street 2:
Mailing Address - City:WAMEGO
Mailing Address - State:KS
Mailing Address - Zip Code:66547-1179
Mailing Address - Country:US
Mailing Address - Phone:785-456-2295
Mailing Address - Fax:785-456-9467
Practice Address - Street 1:711 GENN DR
Practice Address - Street 2:
Practice Address - City:WAMEGO
Practice Address - State:KS
Practice Address - Zip Code:66547-1179
Practice Address - Country:US
Practice Address - Phone:785-456-2295
Practice Address - Fax:785-456-9467
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS44166363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS13-36365-071OtherREGISTERED NURSE
KS44166OtherLICENSE #
KS100280380EMedicaid
KS363LF0000XOtherTAXONOMY
KS363LF0000XOtherTAXONOMY
KS13-36365-071OtherREGISTERED NURSE
KS161262Medicare ID - Type UnspecifiedPROVIDER #