Provider Demographics
NPI:1114292257
Name:FORHOLT, KATHERINE M (ARNP)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:M
Last Name:FORHOLT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:M
Other - Last Name:CRAIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-312-3457
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:1223 GATEWAY DR # 1C
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-312-3457
Practice Address - Fax:321-674-9196
Is Sole Proprietor?:No
Enumeration Date:2012-03-21
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9273175363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0FZ6OtherFLORIDA BLUE (BCBS)
FL9273175OtherSTATE ARNP LICENSE NUMBER
FL9416992OtherAETNA
FLP01165503OtherRR MEDICARE
FLP01165503OtherRR MEDICARE