Provider Demographics
NPI:1144791690
Name:CANCEL, KATHERINE ELAINE (APRN)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELAINE
Last Name:CANCEL
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 1:802 W DR MARTIN LUTHER KING JR BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33563-5105
Mailing Address - Country:US
Mailing Address - Phone:727-754-1496
Mailing Address - Fax:813-754-2553
Practice Address - Street 1:802 W DR MARTIN LUTHER KING JR BLVD STE D
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-5105
Practice Address - Country:US
Practice Address - Phone:727-754-1496
Practice Address - Fax:813-754-2553
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-10
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11000097363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC524-505-87-771-1OtherFLORIDA DEPARTMENT OF DRIVERS LICENSE