Basic Information
| Provider Information | |||||||||
| NPI: | 1982290953 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALONSO | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | KATHRYN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | APRN, CPNP-PC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ALONSO | ||||||||
| OtherFirstName: | KATIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | APRN, CPNP-PC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 776879 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725339 | ||||||||
| Practice Location | |||||||||
| Address1: | 411 E CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025880850 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2020 | ||||||||
| LastUpdateDate: | 02/09/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3015577 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0200X | 3015577 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.