Healthcare Provider Details

I. General information

NPI: 1427055086
Provider Name (Legal Business Name): KATHRYN MARIE STEVENSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 12/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 US HIGHWAY 395 N
GARDNERVILLE NV
89410-5304
US

IV. Provider business mailing address

1111 EMERALD BAY RD
SOUTH LAKE TAHOE CA
96150-6207
US

V. Phone/Fax

Practice location:
  • Phone: 775-782-1695
  • Fax: 775-782-1558
Mailing address:
  • Phone: 530-543-5979
  • Fax: 530-541-8723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number10544
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: