Provider Demographics
NPI:1740257682
Name:ROE, KATHLEEN S (RN)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:S
Last Name:ROE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 S BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:FL
Mailing Address - Zip Code:34266-3387
Mailing Address - Country:US
Mailing Address - Phone:863-491-7580
Mailing Address - Fax:863-491-7584
Practice Address - Street 1:34 S BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:FL
Practice Address - Zip Code:34266-3387
Practice Address - Country:US
Practice Address - Phone:863-491-7580
Practice Address - Fax:863-491-7584
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL669112163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3100723-00Medicaid