Healthcare Provider Details

I. General information

NPI: 1770584070
Provider Name (Legal Business Name): KATHLEEN M FERNAN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 09/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SOUTH MILL STREET
RIDGWAY PA
15853
US

IV. Provider business mailing address

200 SOUTH MILL STREET
RIDGWAY PA
15853
US

V. Phone/Fax

Practice location:
  • Phone: 814-772-0722
  • Fax: 814-772-6934
Mailing address:
  • Phone: 814-772-0722
  • Fax: 814-772-6934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS013170
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberOS013170
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: