MEDICARE: KATHERINE KELLY LIDZ ARNP

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	ARNP9424269	FL
2	163WP0808X	Psychiatric/Mental Health Registered Nurse	RN9424269	FL

General Provider Information

NPI Number	:	1861809998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHERINE KELLY LIDZ ARNP

Provider Business Mailing Address
First Line	:	1983 NEWBERRY LN
Second Line	:
City	:	TEGA CAY
State	:	SC
Zip	:	29708-8438
Country	:	US
Telephone Number	:	803-619-9846
Fax Number	:	803-913-5275

Provider Business Practice Location Address
First Line	:	6520 SW THISTLE TER
Second Line	:
City	:	PALM CITY
State	:	FL
Zip	:	34990-3857
Country	:	US
Telephone Number	:	803-619-9846
Fax Number	:

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

Provider Enumeration Date	:	07/21/2014
Last Update Date	:	05/05/2025

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