Provider Demographics
NPI:1801789516
Name:ISIDORT, MARIE KETLIE
Entity type:Individual
Prefix:
First Name:MARIE KETLIE
Middle Name:
Last Name:ISIDORT
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 1:238 GREENBRIAR DR
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33403-2726
Mailing Address - Country:US
Mailing Address - Phone:561-506-2280
Mailing Address - Fax:
Practice Address - Street 1:12977 SOUTHERN BLVD STE 202
Practice Address - Street 2:
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-9256
Practice Address - Country:US
Practice Address - Phone:561-879-4006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-02
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11039224363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily