Healthcare Provider Details

I. General information

NPI: 1699614545
Provider Name (Legal Business Name): AMRITA GAVRIELLE KAUSHAL GUNDAVDA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 S PENINSULA DR
DAYTONA BEACH FL
32118-4422
US

IV. Provider business mailing address

1050 HENDRICKS AVE UNIT 104
JACKSONVILLE FL
32207-8360
US

V. Phone/Fax

Practice location:
  • Phone: 386-310-2160
  • Fax: 386-310-2106
Mailing address:
  • Phone: 571-287-0190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9122418
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: