Provider Demographics
NPI:1306315825
Name:WILLINGHAM, KATHERINE NICOLE (APRN)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:NICOLE
Last Name:WILLINGHAM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2151 SW BARTHEL ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-4301
Mailing Address - Country:US
Mailing Address - Phone:772-785-9419
Mailing Address - Fax:
Practice Address - Street 1:2151 SW BARTHEL ST
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34984-4301
Practice Address - Country:US
Practice Address - Phone:772-785-9419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11000064363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily