=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174546717
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHLEEN MOBLEY M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2006
-----------------------------------------------------
Last Update Date | 05/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11375 CORTEZ BLVD
-----------------------------------------------------
City | BROOKSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34613-5409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-665-4614
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 60100
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29419-0100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-664-3939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number | ME51280
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------