Healthcare Provider Details

I. General information

NPI: 1790062479
Provider Name (Legal Business Name): KATHRYN MITTS RN, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHRYN WELTY RN, CDE

II. Dates (important events)

Enumeration Date: 11/09/2011
Last Update Date: 11/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 TESCONI CIR SUITE B
SANTA ROSA CA
95401-4617
US

IV. Provider business mailing address

365 TESCONI CIR SUITE B
SANTA ROSA CA
95401-4617
US

V. Phone/Fax

Practice location:
  • Phone: 707-575-6043
  • Fax: 707-575-1060
Mailing address:
  • Phone: 707-575-6043
  • Fax: 707-575-1060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number609840
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: