Provider Demographics
NPI:1013019603
Name:BASTONE, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:BASTONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17200 PERU RD
Mailing Address - Street 2:
Mailing Address - City:UMATILLA
Mailing Address - State:FL
Mailing Address - Zip Code:32784-9359
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:570 HATFIELD DR
Practice Address - Street 2:
Practice Address - City:UMATILLA
Practice Address - State:FL
Practice Address - Zip Code:32784-8986
Practice Address - Country:US
Practice Address - Phone:352-669-6888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156FX1800X
FLAS2700237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2100002OtherUNITED HEALTHCARE
FL610136400Medicaid
FL593024353OtherI.D. NUMBER
FL086623700Medicaid
FL086623701Medicaid
FLFL3146OtherEYE MED
FL086623701Medicaid