Provider Demographics
NPI:1942773296
Name:IMBORDINO, KATHRYN (APRN)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:IMBORDINO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:BEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3601 W COMMERCIAL BLVD STE 5
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3392
Mailing Address - Country:US
Mailing Address - Phone:954-485-5666
Mailing Address - Fax:954-484-1651
Practice Address - Street 1:300 PASTEUR DR
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-2200
Practice Address - Country:US
Practice Address - Phone:650-723-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11000886367500000X
CA95001513367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102065100Medicaid