Basic Information
Provider Information | |||||||||
NPI: | 1891707113 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KEMSLEY | ||||||||
FirstName: | JOAN | ||||||||
MiddleName: | O | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4371 VERONICA S SHOEMAKER BLVD | ||||||||
Address2: | ATTN: CREDENTIALING | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 339162216 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2392748200 | ||||||||
FaxNumber: | 2392783350 | ||||||||
Practice Location | |||||||||
Address1: | 18308 MURDOCK CIR | ||||||||
Address2: | UNIT 105 | ||||||||
City: | PT CHARLOTTE | ||||||||
State: | FL | ||||||||
PostalCode: | 339481025 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9417434150 | ||||||||
FaxNumber: | 9417434427 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/13/2006 | ||||||||
LastUpdateDate: | 12/03/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9103170 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 9834304 | 01 | FL | AETNA | OTHER | Y0NY8 | 01 | FL | BCBS | OTHER | P01406349 | 01 | FL | RR MEDICARE | OTHER | 9308885 | 01 | FL | CIGNA | OTHER | P04453 | 01 | FL | FREEDOM | OTHER | 292061100 | 05 | FL |   | MEDICAID | P959330 | 01 | FL | OPTIMUM | OTHER |