Healthcare Provider Details

I. General information

NPI: 1336329523
Provider Name (Legal Business Name): KATHRYN ANN WERNER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHRYN ANN HARRIS PA

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 12/16/2021
Certification Date: 12/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3527 S FEDERAL WAY SUITE 103-424
BOISE ID
83705-5204
US

IV. Provider business mailing address

2008 WYNFIELD DR.
PRATTVILLE AL
36067-7157
US

V. Phone/Fax

Practice location:
  • Phone: 208-391-7280
  • Fax: 534-202-4595
Mailing address:
  • Phone: 208-391-7280
  • Fax: 534-202-4595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License NumberPA1284
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License NumberPA1373
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1373
License Number StateAL
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1284
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: