Provider Demographics
NPI:1376861096
Name:AUGUSTINE, KATHLEEN MARIE (CNM)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:AUGUSTINE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:MARIE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP, CNM
Mailing Address - Street 1:PO BOX 748817
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8817
Mailing Address - Country:US
Mailing Address - Phone:813-286-0033
Mailing Address - Fax:407-303-1446
Practice Address - Street 1:1116 LUCERNE TER
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1017
Practice Address - Country:US
Practice Address - Phone:407-316-8550
Practice Address - Fax:407-316-8311
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-05
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9185846367A00000X, 363LW0102X, 363LW0102X
SC20877367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015463600Medicaid
SCMW0250Medicaid