Provider Demographics
NPI:1861770166
Name:DEREVERE, KATI M (PMHNP)
Entity type:Individual
Prefix:MISS
First Name:KATI
Middle Name:M
Last Name:DEREVERE
Suffix:
Gender:F
Credentials:PMHNP
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 687
Mailing Address - Street 2:
Mailing Address - City:MOUNT DESERT
Mailing Address - State:ME
Mailing Address - Zip Code:04660-0687
Mailing Address - Country:US
Mailing Address - Phone:207-244-4111
Mailing Address - Fax:207-244-4114
Practice Address - Street 1:1049 MAIN STREET
Practice Address - Street 2:UNIT 2S
Practice Address - City:MOUNT DESERT
Practice Address - State:ME
Practice Address - Zip Code:04660
Practice Address - Country:US
Practice Address - Phone:207-244-4111
Practice Address - Fax:207-244-4114
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERO49940163WP0808X
MECNP111084363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME002487902Medicare PIN