Provider Demographics
NPI:1699331470
Name:RIDORE, KATYA VICTORIA (FNP)
Entity type:Individual
Prefix:
First Name:KATYA
Middle Name:VICTORIA
Last Name:RIDORE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 S RONALD REAGAN BLVD
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-5404
Mailing Address - Country:US
Mailing Address - Phone:407-637-5656
Mailing Address - Fax:
Practice Address - Street 1:315 S RONALD REAGAN BLVD
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-5404
Practice Address - Country:US
Practice Address - Phone:407-637-5656
Practice Address - Fax:407-637-5725
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11005676363LF0000X
FL11005676363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112849800Medicaid
FLOQ279OtherMEDICARE