Provider Demographics
NPI:1255861548
Name:CAMMACK, KATHERINE MARIE (SZ)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MARIE
Last Name:CAMMACK
Suffix:
Gender:F
Credentials:SZ
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 S WINTERHAWK DR UNIT 107
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-3870
Mailing Address - Country:US
Mailing Address - Phone:904-217-3914
Mailing Address - Fax:904-217-3892
Practice Address - Street 1:910 S WINTERHAWK DR UNIT 107
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3870
Practice Address - Country:US
Practice Address - Phone:904-217-3914
Practice Address - Fax:904-217-3892
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-19
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ8086235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSZ8086OtherDEPARTMETN OF HEALTH