Basic Information
| Provider Information | |||||||||
| NPI: | 1316921430 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ERICKSON | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | CLYDEAN | ||||||||
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| Credential: | RN, CS, FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 E EVERGREEN ST | ||||||||
| Address2: | PO BOX 557 | ||||||||
| City: | CAMERON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 644292400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8166322101 | ||||||||
| FaxNumber: | 8166493383 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 E EVERGREEN ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | CAMERON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 644292400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8166322139 | ||||||||
| FaxNumber: | 8166322315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2005 | ||||||||
| LastUpdateDate: | 12/02/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 065142 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LG0600X | 065142 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 427786421 | 05 | MO | MEDICAID | P00607932 | 01 | MO | MEDICARE RAILROAD | OTHER |