Provider Demographics
NPI:1376800524
Name:MORMAN, KATHY ANN I
Entity Type:Individual
Prefix:MISS
First Name:KATHY
Middle Name:ANN
Last Name:MORMAN
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:ANN
Other - Last Name:MORMAN
Other - Suffix:I
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12750 NW 27TH AVE APT 27TH
Mailing Address - Street 2:
Mailing Address - City:OPA LOCKA
Mailing Address - State:FL
Mailing Address - Zip Code:33054-7027
Mailing Address - Country:US
Mailing Address - Phone:786-970-8485
Mailing Address - Fax:
Practice Address - Street 1:12750 NW 27TH AVE APT 27TH
Practice Address - Street 2:
Practice Address - City:OPA- LOCKA
Practice Address - State:FL
Practice Address - Zip Code:33054-7027
Practice Address - Country:US
Practice Address - Phone:786-970-8485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL003938000171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003938000Medicaid