Provider Demographics
NPI:1689242463
Name:MATHENEY, KAITLYN CONNOR (APRN)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:CONNOR
Last Name:MATHENEY
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 1:160 AUTUMN AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:FL
Mailing Address - Zip Code:32439-4250
Mailing Address - Country:US
Mailing Address - Phone:270-508-0745
Mailing Address - Fax:
Practice Address - Street 1:5551 US HIGHWAY 98 W
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-3566
Practice Address - Country:US
Practice Address - Phone:205-565-1232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28406363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN28406Medicaid