Provider Demographics
NPI:1053363762
Name:BREAULT, KATHLEEN A (CNM)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:BREAULT
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 FIFTEENTH STREET
Mailing Address - Street 2:CAPITAL REGION MIDWIFERY
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180
Mailing Address - Country:US
Mailing Address - Phone:518-326-1620
Mailing Address - Fax:518-326-1622
Practice Address - Street 1:1 ATWELL RD
Practice Address - Street 2:
Practice Address - City:COOPERSTOWN
Practice Address - State:NY
Practice Address - Zip Code:13326-1301
Practice Address - Country:US
Practice Address - Phone:607-547-3909
Practice Address - Fax:607-547-6325
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF000561367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01780170Medicaid
NYU71003Medicare ID - Type UnspecifiedUPSTATE
NY01780170Medicaid