MEDICARE: MRS. KATHY MARIE WOLVERTON CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	075728	NC

General Provider Information

NPI Number	:	1023092921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATHY MARIE WOLVERTON CRNA

Provider Business Mailing Address
First Line	:	111 COUNTRY CIR
Second Line	:
City	:	ADVANCE
State	:	NC
Zip	:	27006-7456
Country	:	US
Telephone Number	:	336-998-7590
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 COUNTRY CIR
Second Line	:
City	:	ADVANCE
State	:	NC
Zip	:	27006-7456
Country	:	US
Telephone Number	:	336-998-7590
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2005
Last Update Date	:	10/18/2007

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