Provider Demographics
NPI:1598351629
Name:MADDEN, KATERIA SHANTAL
Entity Type:Individual
Prefix:
First Name:KATERIA
Middle Name:SHANTAL
Last Name:MADDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KATERIA
Other - Middle Name:SHANTAL
Other - Last Name:MADDEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1065 MATHERS ST
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-6176
Mailing Address - Country:US
Mailing Address - Phone:407-820-4041
Mailing Address - Fax:
Practice Address - Street 1:1065 MATHERS ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-6176
Practice Address - Country:US
Practice Address - Phone:407-820-4041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-13
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLM350517938860Medicaid