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General NPI Number Information
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NPI Number | 1114057510
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Entity Type | Individual
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Provider Name | KATHLEEN MARIE BOOTH RNC, NP
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Gender | Female
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Dates
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Enumeration Date | 03/06/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2115 SUMMIT AVE STUDENT HEALTH SERVICES # 5056
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City | ST PAUL
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State | MN
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Zip | 55105
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Country | US
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Telephone | 651-962-6750
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Fax | 651-962-6751
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Provider Business Mailing Address
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Address Line | 7 RED PINE RD
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City | NORTH OAKS
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State | MN
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Zip | 55127-2030
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Country | US
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Telephone | 651-490-7863
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Fax | 651-490-7863
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | R1226809
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License Number State | MN
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