Basic Information
| Provider Information | |||||||||
| NPI: | 1285738336 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHEOM | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LNM CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 17 EAST HAYCOCK ROAD | ||||||||
| Address2: | |||||||||
| City: | BRANFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034887035 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 374 GRAND AVENUE | ||||||||
| Address2: | FAIR HAVEN COMMUNITY HEALTH CTR | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037777411 | ||||||||
| FaxNumber: | 2037778506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 000021 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 0000219734 | 01 | CONNECTICARE | OTHER | 400000021CT01 | 01 | ANTHEM BCBS | OTHER | PSS4934 | 01 | OXFORD | OTHER |