Healthcare Provider Details

I. General information

NPI: 1982934915
Provider Name (Legal Business Name): ATHINA LYNN KYRITSIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2010
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25243 ELEMENTARY WAY SUITE 103
BONITA SPRINGS FL
34135
US

IV. Provider business mailing address

25243 ELEMENTARY WAY SUITE 103
BONITA SPRINGS FL
34135
US

V. Phone/Fax

Practice location:
  • Phone: 239-498-9114
  • Fax: 239-498-6555
Mailing address:
  • Phone: 239-498-9114
  • Fax: 239-498-6555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0066650
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME0066650
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: