=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225653819
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KARA C GRAYDON ARNP, FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2020
-----------------------------------------------------
Last Update Date | 06/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 643 CAPE CORAL PKWY E
-----------------------------------------------------
City | CAPE CORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33904-8549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 567-525-2195
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 141 SE 5TH ST
-----------------------------------------------------
City | CAPE CORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33990-1056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 567-525-2195
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN11003384
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------