Provider Demographics
NPI:1689646317
Name:MCMICKEN, KATHLEEN DEKOVEN (ARNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:DEKOVEN
Last Name:MCMICKEN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 95004
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33804
Mailing Address - Country:US
Mailing Address - Phone:863-680-7206
Mailing Address - Fax:863-680-7420
Practice Address - Street 1:2250 OSPREY BLVD
Practice Address - Street 2:STE 100
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830
Practice Address - Country:US
Practice Address - Phone:863-533-7151
Practice Address - Fax:863-533-7214
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP528982363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
R73929Medicare UPIN
FLY4863YMedicare PIN