Provider Demographics
NPI:1053737973
Name:OVERBERG, KATHRYN B (APRN)
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:B
Last Name:OVERBERG
Suffix:
Gender:F
Credentials:APRN
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 122
Mailing Address - Street 2:300 SANDRIDGE RD EAST
Mailing Address - City:WACO
Mailing Address - State:KY
Mailing Address - Zip Code:40385-0122
Mailing Address - Country:US
Mailing Address - Phone:716-467-1104
Mailing Address - Fax:
Practice Address - Street 1:9510 ORMSBY STATION RD STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-4082
Practice Address - Country:US
Practice Address - Phone:502-327-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008565363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100311950Medicaid
12678456OtherCAQH