Provider Demographics
NPI:1174873772
Name:MENDHEIM, KATHLEEN (CRNP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MENDHEIM
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:C
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:287 HEALTHWEST DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-2031
Mailing Address - Country:US
Mailing Address - Phone:334-792-9500
Mailing Address - Fax:334-793-1815
Practice Address - Street 1:287 HEALTHWEST DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-2031
Practice Address - Country:US
Practice Address - Phone:334-792-9500
Practice Address - Fax:334-793-1815
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2017-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-110354363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL511-57591OtherBC/BS AL
AL511-57583OtherBC/BS AL
AL1-110354OtherALABAMA NURSING LICENSE