Healthcare Provider Details

I. General information

NPI: 1639767908
Provider Name (Legal Business Name): KATIE MORAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2021
Last Update Date: 04/05/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5905 US 301 S
RIVERVIEW FL
33578-3800
US

IV. Provider business mailing address

12103 NIGHT JASMINE CV
RIVERVIEW FL
33579-9319
US

V. Phone/Fax

Practice location:
  • Phone: 727-822-7115
  • Fax:
Mailing address:
  • Phone: 954-806-8267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9563869
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11012356
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: