Provider Demographics
NPI:1275599821
Name:FILL, KATHLEEN (CRNA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:FILL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12738 TAR FLOWER DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-2340
Mailing Address - Country:US
Mailing Address - Phone:586-530-7492
Mailing Address - Fax:
Practice Address - Street 1:12902 USF MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9416
Practice Address - Country:US
Practice Address - Phone:813-745-8486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9230422367500000X
AZRN 133359367500000X
MI4704136398367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG3924OtherBCBS
FLG3924OtherBCBS
FLU7077ZMedicare ID - Type Unspecified
MIN47230065Medicare ID - Type UnspecifiedLOC 99
FL0TH000Medicare UPIN