Healthcare Provider Details

I. General information

NPI: 1689646317
Provider Name (Legal Business Name): KATHLEEN DEKOVEN MCMICKEN ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 OSPREY BLVD STE 100
BARTOW FL
33830
US

IV. Provider business mailing address

PO BOX 95004
LAKELAND FL
33804
US

V. Phone/Fax

Practice location:
  • Phone: 863-533-7151
  • Fax: 863-533-7214
Mailing address:
  • Phone: 863-680-7206
  • Fax: 863-680-7420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP528982
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: