Basic Information
| Provider Information | |||||||||
| NPI: | 1295361913 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VIBBERT | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | MELISSA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2603 EAGLE CLIFF DR | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347463174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4077290890 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11750 E COLONIAL DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328174656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8446654827 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2020 | ||||||||
| LastUpdateDate: | 03/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 9112986 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.