Provider Demographics
NPI:1053087114
Name:YANCEY, KATHLEEN (RD, PA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:YANCEY
Suffix:
Gender:F
Credentials:RD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 IRONRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-5747
Mailing Address - Country:US
Mailing Address - Phone:904-614-0670
Mailing Address - Fax:
Practice Address - Street 1:906 PARK AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4120
Practice Address - Country:US
Practice Address - Phone:904-541-0315
Practice Address - Fax:904-541-0316
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND7019133V00000X
FLPA9115044363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered