Healthcare Provider Details

I. General information

NPI: 1083294839
Provider Name (Legal Business Name): KAITLYN DUCKWORTH DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 SERVICE PL STE 200
VISTA CA
92084-7271
US

IV. Provider business mailing address

3633 VISTA WAY STE 101
OCEANSIDE CA
92056-4568
US

V. Phone/Fax

Practice location:
  • Phone: 760-842-8824
  • Fax: 760-650-7788
Mailing address:
  • Phone: 760-729-7298
  • Fax: 760-729-7206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number299750
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number299750
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: