Basic Information
| Provider Information | |||||||||
| NPI: | 1710653076 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERRMANN | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | KELSEY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RDH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 34 | ||||||||
| Address2: | |||||||||
| City: | BLOSSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 169120034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706383468 | ||||||||
| FaxNumber: | 5706383637 | ||||||||
| Practice Location | |||||||||
| Address1: | 116 SEYMOUR ST | ||||||||
| Address2: | |||||||||
| City: | BLOSSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 169121418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706383468 | ||||||||
| FaxNumber: | 5706383637 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2021 | ||||||||
| LastUpdateDate: | 08/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223D0001X | PHDH001210 | PA | N | Dental Providers | Dentist | Dental Public Health | 124Q00000X | DH071683 | PA | Y | Dental Providers | Dental Hygienist |
No ID Information.