Provider Demographics
NPI:1619190105
Name:UDELL, KATHRYN JEAN (APRN)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:JEAN
Last Name:UDELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-590-2612
Practice Address - Street 1:13774 PLANTATION RD STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4461
Practice Address - Country:US
Practice Address - Phone:239-236-7777
Practice Address - Fax:239-245-7028
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN1280482363LA2200X
MA188339363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL30223400Medicaid
FL30223400Medicaid