Healthcare Provider Details

I. General information

NPI: 1902801616
Provider Name (Legal Business Name): KATHARINE ADELE SEVERSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

899 SPRING ST
PLACERVILLE CA
95667-4437
US

IV. Provider business mailing address

7014 STOPE CT
PLACERVILLE CA
95667-8333
US

V. Phone/Fax

Practice location:
  • Phone: 530-621-3600
  • Fax: 530-621-3668
Mailing address:
  • Phone: 530-642-1787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberFNP 8714
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: