Provider Demographics
NPI:1487948659
Name:SACRED HEART MEDICAL GROUP
Entity type:Organization
Organization Name:SACRED HEART MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:AUDELL
Authorized Official - Last Name:PIBURN
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:251-709-6297
Mailing Address - Street 1:5147 N 9TH AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8771
Mailing Address - Country:US
Mailing Address - Phone:850-416-6886
Mailing Address - Fax:
Practice Address - Street 1:5147 N 9TH AVE STE 103
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8771
Practice Address - Country:US
Practice Address - Phone:850-416-6886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9324383261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care