MEDICARE: MRS. KATHERINE NICOLE WILLINGHAM APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	APRN11000064	FL

General Provider Information

NPI Number	:	1306315825
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATHERINE NICOLE WILLINGHAM APRN

Provider Business Mailing Address
First Line	:	2151 SW BARTHEL ST
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34984-4301
Country	:	US
Telephone Number	:	772-785-9419
Fax Number	:

Provider Business Practice Location Address
First Line	:	2151 SW BARTHEL ST
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34984-4301
Country	:	US
Telephone Number	:	772-785-9419
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2018
Last Update Date	:	11/14/2018

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