1679760086 NPI number — MRS. KATHLEEN ANN SHARKEY

Table of content: MRS. KATHLEEN ANN SHARKEY (NPI 1679760086)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679760086 NPI number — MRS. KATHLEEN ANN SHARKEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHARKEY
Provider First Name:
KATHLEEN
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FORD
Provider Other First Name:
KATHLEEN
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
ARNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679760086
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 102222
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30368-2222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 SE OCEAN BLVD STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STUART
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34994-2236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-287-4061
Provider Business Practice Location Address Fax Number:
772-287-4176
Provider Enumeration Date:
09/29/2007

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: 363L00000X , with the licence number:  ARNP1229482 , 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: 102028100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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