Provider Demographics
NPI:1467758870
Name:RICHARDSON, KATJA DIENEEN
Entity Type:Individual
Prefix:MRS
First Name:KATJA
Middle Name:DIENEEN
Last Name:RICHARDSON
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 1:724 NORTH K STREET
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501
Mailing Address - Country:US
Mailing Address - Phone:850-516-1471
Mailing Address - Fax:
Practice Address - Street 1:724 N K ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-2729
Practice Address - Country:US
Practice Address - Phone:850-516-1471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA451953747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL193400000XMedicare Oscar/Certification