MEDICARE: KATHLEEN K MCDANIEL PNP

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	363LP0200X	Pediatric Nurse Practitioner	00022502	OR

General Provider Information

NPI Number	:	1508922154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN K MCDANIEL PNP

Provider Business Mailing Address
First Line	:	254 NE NORTON LN
Second Line	:
City	:	MCMINNVILLE
State	:	OR
Zip	:	97128-8470
Country	:	US
Telephone Number	:	503-472-6161
Fax Number	:	503-434-6290

Provider Business Practice Location Address
First Line	:	254 NE NORTON LN
Second Line	:
City	:	MCMINNVILLE
State	:	OR
Zip	:	97128-8470
Country	:	US
Telephone Number	:	503-472-6161
Fax Number	:	503-434-6290

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

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	11/07/2007

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