Provider Demographics
NPI:1386376762
Name:PACOCHA, KATELYN
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:PACOCHA
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 1:6049 WINDING LAKE DR
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-3777
Mailing Address - Country:US
Mailing Address - Phone:484-574-4554
Mailing Address - Fax:
Practice Address - Street 1:1005 JOE DIMAGGIO DR
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-5402
Practice Address - Country:US
Practice Address - Phone:484-574-4554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-25
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL11021525363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program