Provider Demographics
NPI:1710284617
Name:ELLERMEYER-STAPLETON, MARY KATHRYN (ARNP-C, ANP)
Entity Type:Individual
Prefix:MRS
First Name:MARY KATHRYN
Middle Name:
Last Name:ELLERMEYER-STAPLETON
Suffix:
Gender:F
Credentials:ARNP-C, ANP
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 91630
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33804-1630
Mailing Address - Country:US
Mailing Address - Phone:863-660-2673
Mailing Address - Fax:
Practice Address - Street 1:1700 BAKER AVE
Practice Address - Street 2:
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844-8839
Practice Address - Country:US
Practice Address - Phone:863-421-3204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-12
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2513482363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014115400Medicaid
FLIA642ZMedicare UPIN