Provider Demographics
NPI:1265688857
Name:YOUNG, KATHRYN JEAN
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:JEAN
Last Name:YOUNG
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 1:13410 MASCOTTE EMPIRE RD
Mailing Address - Street 2:
Mailing Address - City:GROVELAND
Mailing Address - State:FL
Mailing Address - Zip Code:34736-9330
Mailing Address - Country:US
Mailing Address - Phone:352-429-3050
Mailing Address - Fax:
Practice Address - Street 1:13410 MASCOTTE EMPIRE RD
Practice Address - Street 2:
Practice Address - City:GROVELAND
Practice Address - State:FL
Practice Address - Zip Code:34736-9330
Practice Address - Country:US
Practice Address - Phone:352-429-3050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-14
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL230587900Medicaid