Basic Information
| Provider Information | |||||||||
| NPI: | 1407838873 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLADDE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | LU | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP, FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GODDEYNE | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | LU | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 100286 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326100286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650535 | ||||||||
| FaxNumber: | 3522651060 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SW ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326104833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650535 | ||||||||
| FaxNumber: | 3522651060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2005 | ||||||||
| LastUpdateDate: | 02/27/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APRN1704522 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 660119700 | 05 | FL | MEDICAID |