Basic Information
| Provider Information | |||||||||
| NPI: | 1689646317 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCMICKEN | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | DEKOVEN | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 95004 | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636807206 | ||||||||
| FaxNumber: | 8636807420 | ||||||||
| Practice Location | |||||||||
| Address1: | 2250 OSPREY BLVD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | BARTOW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8635337151 | ||||||||
| FaxNumber: | 8635337214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 10/31/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP528982 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.