MEDICARE: KATHY DIANE REID APRN,BC

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	363LG0600X	Gerontology Nurse Practitioner	4704133106	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174525042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHY DIANE REID APRN,BC

Provider Business Mailing Address
First Line	:	10850 E TRAVERSE HWY
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-1364
Country	:	US
Telephone Number	:	231-346-6930
Fax Number	:	231-346-6017

Provider Business Practice Location Address
First Line	:	1000 PAVILLIONS CIR
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-3198
Country	:	US
Telephone Number	:	231-932-3801
Fax Number	:	231-421-3789

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

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	10/28/2015

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