Basic Information
| Provider Information | |||||||||
| NPI: | 1558377598 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DONALDSON | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 732973 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753732973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177028450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1300 W TERRELL AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177029000 | ||||||||
| FaxNumber: | 8177025167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 09/10/2018 | ||||||||
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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 | 367A00000X | 521931 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 164485803 | 05 | TX | MEDICAID | 8N8822 | 01 | TX | BCBS | OTHER |