Provider Demographics
NPI:1174525042
Name:REID, KATHY DIANE (APRN,BC)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:DIANE
Last Name:REID
Suffix:
Gender:F
Credentials:APRN,BC
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Mailing Address - Street 1:10850 E TRAVERSE HWY
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-1364
Mailing Address - Country:US
Mailing Address - Phone:231-346-6930
Mailing Address - Fax:231-346-6017
Practice Address - Street 1:1000 PAVILLIONS CIR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-3198
Practice Address - Country:US
Practice Address - Phone:231-932-3801
Practice Address - Fax:231-421-3789
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2015-10-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4704133106363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4570969Medicaid
MI4570969Medicaid