Healthcare Provider Details

I. General information

NPI: 1205413309
Provider Name (Legal Business Name): KAITLYN WATHEN WEST DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAITLYN ELIZABETH WATHEN

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BRECKENRIDGE ST STE 300
OWENSBORO KY
42303
US

IV. Provider business mailing address

PO BOX 23229
OWENSBORO KY
42304-3229
US

V. Phone/Fax

Practice location:
  • Phone: 270-688-4480
  • Fax: 270-688-4489
Mailing address:
  • Phone: 270-688-1330
  • Fax: 270-688-1338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number05717
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: