Healthcare Provider Details

I. General information

NPI: 1609602648
Provider Name (Legal Business Name): KAYLA ROBERTA CICCOTTO APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6410 W GULF TO LAKE HWY
CRYSTAL RIVER FL
34429-7622
US

IV. Provider business mailing address

5291 W RANGER ST
BEVERLY HILLS FL
34465-4684
US

V. Phone/Fax

Practice location:
  • Phone: 352-563-2450
  • Fax:
Mailing address:
  • Phone: 352-476-2041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11035127
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: