Healthcare Provider Details

I. General information

NPI: 1427032432
Provider Name (Legal Business Name): KATHY L BOOTHBY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 02/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 ATLANTIC PL BEACON HOSPICE/AMEDISYS
SOUTH PORTLAND ME
04106-2316
US

IV. Provider business mailing address

54 ATLANTIC PL BEACON HOSPICE/AMEDISYS
SOUTH PORTLAND ME
04106-2316
US

V. Phone/Fax

Practice location:
  • Phone: 207-772-0929
  • Fax:
Mailing address:
  • Phone: 207-772-0929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number036390-23
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCNP81113
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: