Provider Demographics
NPI:1891137030
Name:FONDREN, KATHERINE ANN (APRN-C)
Entity Type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:ANN
Last Name:FONDREN
Suffix:
Gender:F
Credentials:APRN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 W DR MLK BLVD FL JR2
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6307
Mailing Address - Country:US
Mailing Address - Phone:813-554-8135
Mailing Address - Fax:813-605-6098
Practice Address - Street 1:3003 W DR MARTIN LUTHER KING JR BLVD FL 2
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6307
Practice Address - Country:US
Practice Address - Phone:813-554-8135
Practice Address - Fax:813-765-6098
Is Sole Proprietor?:No
Enumeration Date:2013-07-29
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9175827363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012933900Medicaid