Healthcare Provider Details

I. General information

NPI: 1194342048
Provider Name (Legal Business Name): KETTELENE PHILOGENE MCMORRIS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2020
Last Update Date: 07/25/2026
Certification Date: 07/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 SW INNOVATION WAY
PORT SAINT LUCIE FL
34987-2111
US

IV. Provider business mailing address

1860 SW FOUNTAINVIEW BLVD STE 100
PORT SAINT LUCIE FL
34986-4528
US

V. Phone/Fax

Practice location:
  • Phone: 772-345-8100
  • Fax:
Mailing address:
  • Phone: 754-366-1406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number350474
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11007657
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9309679
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704451405
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number40756
License Number StateTN
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5023205
License Number StateNC
# 7
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN2374100
License Number StateMA
# 8
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberC-APN-0004597-C-NP
License Number StateCO
# 9
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number277.005077
License Number StateIL
# 10
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number17052
License Number StateCT
# 11
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number88570
License Number StateNM
# 12
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11007657
License Number StateFL
# 13
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10057847
License Number StateOR
# 14
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number118367-23
License Number StateNH
# 15
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ14912700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: