Healthcare Provider Details

I. General information

NPI: 1548617566
Provider Name (Legal Business Name): KATHLEEN ANN MINTON PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KAM MCCULLOCH

II. Dates (important events)

Enumeration Date: 05/19/2016
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 ANTHONY DR
ANTHONY NM
88021-9366
US

IV. Provider business mailing address

477 OAK TREE CT
EL PASO TX
79932-3140
US

V. Phone/Fax

Practice location:
  • Phone: 817-528-5260
  • Fax:
Mailing address:
  • Phone: 817-528-5260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number889319
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number70742
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: