Basic Information
| Provider Information | |||||||||
| NPI: | 1205130820 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HABERSTRO | ||||||||
| OtherFirstName: | KATHERINE | ||||||||
| OtherMiddleName: | GRACE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 PILLSBURY ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CONCORD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 033013556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6032244776 | ||||||||
| FaxNumber: | 6032282113 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 PILLSBURY ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CONCORD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 033013556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6032244776 | ||||||||
| FaxNumber: | 6032282113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2010 | ||||||||
| LastUpdateDate: | 12/15/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 063727-23 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 30348607 | 05 | NH | MEDICAID |