Basic Information
Provider Information | |||||||||
NPI: | 1588200885 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ERICKSON | ||||||||
FirstName: | KATHRYN | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HEMMY | ||||||||
OtherFirstName: | KATHRYN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5338 PLANTATION HOME WAY | ||||||||
Address2: |   | ||||||||
City: | PORT ORANGE | ||||||||
State: | FL | ||||||||
PostalCode: | 321287529 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3863332235 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1630 MASON AVE STE C | ||||||||
Address2: |   | ||||||||
City: | DAYTONA BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 321174503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3862389064 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/21/2019 | ||||||||
LastUpdateDate: | 01/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | AG11005008 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.