Basic Information
Provider Information | |||||||||
NPI: | 1225055833 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PAWLANTA | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | F.N.P. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DONNELLY | ||||||||
OtherFirstName: | KATHLEEN | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | F.N.P. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 829 N CENTER AVE | ||||||||
Address2: | SUITE 298 | ||||||||
City: | GAYLORD | ||||||||
State: | MI | ||||||||
PostalCode: | 497351595 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9897317708 | ||||||||
FaxNumber: | 9897317929 | ||||||||
Practice Location | |||||||||
Address1: | 829 N CENTER AVE | ||||||||
Address2: | SUITE 210 | ||||||||
City: | GAYLORD | ||||||||
State: | MI | ||||||||
PostalCode: | 497351595 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9897317860 | ||||||||
FaxNumber: | 9897317954 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2006 | ||||||||
LastUpdateDate: | 12/23/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/23/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704196460 | MI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | DC6258 | 01 |   | MEDICARE RR PROV ID | OTHER | 381303843 | 01 |   | TAX ID | OTHER | 4600629 | 05 | MI |   | MEDICAID | OF96004 | 01 |   | MEDICARE GROUP NUMBER | OTHER |