Healthcare Provider Details

I. General information

NPI: 1366219222
Provider Name (Legal Business Name): KATHRYN MOYNIHAN PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2023
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6511 GUNN HWY
TAMPA FL
33625-4021
US

IV. Provider business mailing address

3330 LAKE HELEN OSTEEN RD
DELTONA FL
32738-1068
US

V. Phone/Fax

Practice location:
  • Phone: 813-605-1122
  • Fax: 813-354-2430
Mailing address:
  • Phone: 407-461-4099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2023154821
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: