Provider Demographics
NPI:1043516958
Name:DETJENS, KATHRYN M (ARNP)
Entity type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:M
Last Name:DETJENS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40480
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36640-0480
Mailing Address - Country:US
Mailing Address - Phone:251-415-1566
Mailing Address - Fax:251-415-1552
Practice Address - Street 1:1700 CENTER ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36604-3301
Practice Address - Country:US
Practice Address - Phone:251-415-1566
Practice Address - Fax:251-415-1552
Is Sole Proprietor?:No
Enumeration Date:2011-02-10
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9225689363LX0001X
AL1-142596367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology