Provider Demographics
NPI:1821788332
Name:PATRICK, KATELYN
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:PATRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10305 CREPE JASMINE LN
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913-8877
Mailing Address - Country:US
Mailing Address - Phone:239-791-6868
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-1000
Practice Address - Country:US
Practice Address - Phone:603-650-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLXXXXXXX367500000X
NH091879-23367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered