Provider Demographics
NPI:1871779652
Name:LAUDERBACK, KATHLEEN D (ARNP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:D
Last Name:LAUDERBACK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 WEKIVA COMMONS CIR
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-3645
Mailing Address - Country:US
Mailing Address - Phone:407-464-9516
Mailing Address - Fax:407-464-9519
Practice Address - Street 1:515 WEKIVA COMMONS CIR
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32712-3645
Practice Address - Country:US
Practice Address - Phone:407-464-9516
Practice Address - Fax:407-464-9519
Is Sole Proprietor?:No
Enumeration Date:2008-01-11
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1611212363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ24175Medicare UPIN
FLU3313ZMedicare PIN