Healthcare Provider Details

I. General information

NPI: 1063749695
Provider Name (Legal Business Name): KATHRYN ANN KABELMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHRYN ANN PATNAUDE PA-C

II. Dates (important events)

Enumeration Date: 11/03/2009
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 S RIVER AVE
HOLLAND MI
49423-3326
US

IV. Provider business mailing address

100 MICHIGAN ST NE MC 845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-394-3788
  • Fax:
Mailing address:
  • Phone: 616-486-6790
  • Fax: 616-486-6702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601055666
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: