Healthcare Provider Details

I. General information

NPI: 1043295090
Provider Name (Legal Business Name): KATHLEEN YOUNG HARRELL ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 07/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17121 RAINBOW TERRACE
ODESSA FL
33556
US

IV. Provider business mailing address

17121 RAINBOW TERRACE
ODESSA FL
33556
US

V. Phone/Fax

Practice location:
  • Phone: 813-749-6707
  • Fax: 813-475-4831
Mailing address:
  • Phone: 813-749-6907
  • Fax: 813-475-4831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2826532
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2826532
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: