Basic Information
Provider Information | |||||||||
NPI: | 1942273008 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WAYBRANT | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1813 W HARVARD AVE | ||||||||
Address2: | STE 201 | ||||||||
City: | ROSEBURG | ||||||||
State: | OR | ||||||||
PostalCode: | 974712754 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5414406390 | ||||||||
FaxNumber: | 5414406392 | ||||||||
Practice Location | |||||||||
Address1: | 1813 W HARVARD AVE | ||||||||
Address2: | STE 201 | ||||||||
City: | ROSEBURG | ||||||||
State: | OR | ||||||||
PostalCode: | 974712754 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5414406390 | ||||||||
FaxNumber: | 5414406392 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/09/2006 | ||||||||
LastUpdateDate: | 11/29/2018 | ||||||||
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 | 207Q00000X | 80045889N1 | OR | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 363LF0000X | 080045889N1 | OR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 168395 | 05 | OR |   | MEDICAID | R103163 | 01 |   | MCR PART B | OTHER | 154971 | 05 | OR |   | MEDICAID |