Basic Information
| Provider Information | |||||||||
| NPI: | 1215414073 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISCHETTI | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROUISSE | ||||||||
| OtherFirstName: | KATHLEEN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9424 SW 56TH PL | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326084332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274888012 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1515 SW ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2018 | ||||||||
| LastUpdateDate: | 01/03/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 9355686 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 100610600 | 05 | FL | MEDICAID |