Healthcare Provider Details

I. General information

NPI: 1609053420
Provider Name (Legal Business Name): KATHRYN LOUISE GAUTHIER RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2008
Last Update Date: 01/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 SCOGGINS DR
DEMOREST GA
30535-5355
US

IV. Provider business mailing address

185 SCOGGINS DR
DEMOREST GA
30535-5355
US

V. Phone/Fax

Practice location:
  • Phone: 706-778-7156
  • Fax: 706-776-7694
Mailing address:
  • Phone: 706-778-7156
  • Fax: 706-776-7694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN120193
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: