Basic Information
Provider Information | |||||||||
NPI: | 1821314683 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SOUTHALL | ||||||||
FirstName: | CATHLEEN | ||||||||
MiddleName: | HELENA | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3300 S FISKE BLVD | ||||||||
Address2: |   | ||||||||
City: | ROCKLEDGE | ||||||||
State: | FL | ||||||||
PostalCode: | 329554306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9043884646 | ||||||||
FaxNumber: | 9043889017 | ||||||||
Practice Location | |||||||||
Address1: | 2606 PARK ST | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322044520 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9043884646 | ||||||||
FaxNumber: | 9043889017 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/19/2010 | ||||||||
LastUpdateDate: | 04/22/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/22/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | ARNP9232015 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.