Provider Demographics
NPI:1730617531
Name:CUNNINGHAM, KATHLEEN (PA-C)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:KATHLEEN
Other - Middle Name:CUNNINGHAM
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6616 S KISSIMMEE ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33616-1313
Mailing Address - Country:US
Mailing Address - Phone:215-514-3578
Mailing Address - Fax:
Practice Address - Street 1:10920 MCKINLEY DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-6471
Practice Address - Country:US
Practice Address - Phone:831-745-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110378363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant