MEDICARE: KATHY L BOOTHBY APRN

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	363LA2200X	Adult Health Nurse Practitioner	036390-23	NH
2	363LA2200X	Adult Health Nurse Practitioner	CNP81113	ME

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
2	1427032432	OTHER	MA	BCBS
3	40Y007193NH01	OTHER		ANTHEM

General Provider Information

NPI Number	:	1427032432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHY L BOOTHBY APRN

Provider Business Mailing Address
First Line	:	54 ATLANTIC PL
Second Line	:	BEACON HOSPICE/AMEDISYS
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04106-2316
Country	:	US
Telephone Number	:	207-772-0929
Fax Number	:

Provider Business Practice Location Address
First Line	:	54 ATLANTIC PL
Second Line	:	BEACON HOSPICE/AMEDISYS
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04106-2316
Country	:	US
Telephone Number	:	207-772-0929
Fax Number	:

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

Provider Enumeration Date	:	12/02/2005
Last Update Date	:	02/27/2017

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