MEDICARE: KATHLEEN ANNE DEICHEN

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	183500000X	Pharmacist	PS56692	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PS56692	OTHER	FL	PHARMACIST LICENSE

General Provider Information

NPI Number	:	1629632534
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN ANNE DEICHEN

Provider Business Mailing Address
First Line	:	242 N ORLANDO AVE
Second Line	:
City	:	MAITLAND
State	:	FL
Zip	:	32751-5506
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	242 N ORLANDO AVE
Second Line	:
City	:	MAITLAND
State	:	FL
Zip	:	32751-5506
Country	:	US
Telephone Number	:	407-599-0210
Fax Number	:

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

Provider Enumeration Date	:	04/25/2019
Last Update Date	:	04/25/2019

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Directions to “ KATHLEEN ANNE DEICHEN ” Practice Location

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