State Wide Dermatology LLC

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

Legal business name

STATE WIDE DERMATOLOGY LLC

Practice address

17121 Rainbow Ter
Odessa, FL 33556-2107

Phone

(813) 749-6907

Fax

(813) 475-7831

NPI assigned

Feb 19, 2014

Last updated

Jul 28, 2014By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Kathleen Y Harrell, ARNPNPI 1043295090

Title

Owner

Phone

(813) 749-6907

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in FL

Enrollment records 1

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Kathleen Young Harrell, ARNP

  • Nurse Practitioner
  • Odessa, FL
  • NPI 1043295090
  Medicare reassignment Care Compare group NPD Authorized official
• Summer Dawn Beuthin, FNP

  • Family Nurse Practitioner
  • Ocala, FL
  • NPI 1225773617
  Medicare reassignment Care Compare group NPD
• Julie Guadron

  • Family Nurse Practitioner
  • St Petersburg, FL
  • NPI 1538829098
  Medicare reassignment Care Compare group NPD
• Debbie Phillips, FNP-C

  • Family Nurse Practitioner
  • Odessa, FL
  • NPI 1932728193

  Single Specialty

  Medicare reassignment Care Compare group NPD
• Christian Sheffield, APRN; FNP-C

  • Pediatric Nurse Practitioner
  • Odessa, FL
  • NPI 1144812868
  Medicare reassignment Care Compare group NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1392768000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1406505600000",
    "number": "1427473073",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "17121 RAINBOW TER",
            "city": "ODESSA",
            "state": "FL",
            "postal_code": "335562107",
            "telephone_number": "813-749-6907",
            "fax_number": "813-475-7831"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "17121 RAINBOW TER",
            "city": "ODESSA",
            "state": "FL",
            "postal_code": "335562107",
            "telephone_number": "813-749-6907",
            "fax_number": "813-475-7831"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "STATE WIDE DERMATOLOGY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-02-19",
        "last_updated": "2014-07-28",
        "status": "A",
        "authorized_official_last_name": "HARRELL",
        "authorized_official_first_name": "KATHLEEN",
        "authorized_official_middle_name": "Y",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "813-749-6907",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "ARNP"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Dermatology Physician in Odessa, FL
• Providers in Odessa, FL by specialty
• Dermatology Physician in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 28, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.