Healthcare Provider Details

I. General information

NPI: 1942273008
Provider Name (Legal Business Name): KATHLEEN M WAYBRANT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 11/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1813 W HARVARD AVE STE 201
ROSEBURG OR
97471-2754
US

IV. Provider business mailing address

1813 W HARVARD AVE STE 201
ROSEBURG OR
97471-2754
US

V. Phone/Fax

Practice location:
  • Phone: 541-440-6390
  • Fax: 541-440-6392
Mailing address:
  • Phone: 541-440-6390
  • Fax: 541-440-6392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number80045889N1
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number080045889N1
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: