Healthcare Provider Details

I. General information

NPI: 1336703461
Provider Name (Legal Business Name): AYESHA FALAK KIETZMAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AYESHA FALAK HUSSAIN

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13944 LAKESHORE BLVD STE C
HUDSON FL
34667-1431
US

IV. Provider business mailing address

PO BOX 198441
ATLANTA GA
30384-8441
US

V. Phone/Fax

Practice location:
  • Phone: 727-605-0252
  • Fax:
Mailing address:
  • Phone: 813-745-7365
  • Fax: 813-449-8618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9112195
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: