Healthcare Provider Details

I. General information

NPI: 1760026652
Provider Name (Legal Business Name): KATHERINE PADINJATH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2019
Last Update Date: 10/23/2022
Certification Date: 10/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 E MAIN ST
BARTOW FL
33830-5006
US

IV. Provider business mailing address

17602 BUCKINGHAM GARDEN DR
LITHIA FL
33547-4333
US

V. Phone/Fax

Practice location:
  • Phone: 863-534-3737
  • Fax: 863-533-6323
Mailing address:
  • Phone: 336-567-5720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11004880
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: