=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366985988
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHARINE GILLY LI FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2016
-----------------------------------------------------
Last Update Date | 02/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 CRECIENTA DR
-----------------------------------------------------
City | SAUSALITO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94965-1806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-952-0111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 CRECIENTA DR
-----------------------------------------------------
City | SAUSALITO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94965-1806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-952-0111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WG0000X
-----------------------------------------------------
Taxonomy Name | General Practice Registered Nurse
-----------------------------------------------------
License Number | RN131730
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | AP09236
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 341656
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 95022284
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------