1366591752 NPI number — MS. KAREN FRANCES ANNE KILKELLY MPT

Table of content: MS. KAREN FRANCES ANNE KILKELLY MPT (NPI 1366591752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366591752 NPI number — MS. KAREN FRANCES ANNE KILKELLY MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KILKELLY
Provider First Name:
KAREN
Provider Middle Name:
FRANCES ANNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CONSOLO
Provider Other First Name:
KAREN
Provider Other Middle Name:
FRANCES ANNE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366591752
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6508 GUNN HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33625-4022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-963-6923
Provider Business Mailing Address Fax Number:
813-264-0768

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6508 GUNN HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33625-4022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-963-6923
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT0017701 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11939501 . This is a "CITRUS HMO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 354702 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 47782 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 101114700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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