MEDICARE: KAITLYN MOTYKA LAT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AL4854	FL

General Provider Information

NPI Number	:	1831654078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLYN MOTYKA LAT, ATC

Provider Business Mailing Address
First Line	:	11399 HENDON DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32246-7110
Country	:	US
Telephone Number	:	904-962-6284
Fax Number	:

Provider Business Practice Location Address
First Line	:	4831 GREENLAND RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-1517
Country	:	US
Telephone Number	:	904-260-3911
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2019
Last Update Date	:	02/01/2019

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