Healthcare Provider Details

I. General information

NPI: 1972171908
Provider Name (Legal Business Name): KASSIE WHITFIELD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2021
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13100 BROXTON BAY DR APT 415
JACKSONVILLE FL
32218-8366
US

IV. Provider business mailing address

7643 GATE PKWY # 104-606
JACKSONVILLE FL
32256-2893
US

V. Phone/Fax

Practice location:
  • Phone: 904-480-1755
  • Fax:
Mailing address:
  • Phone: 904-480-1755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: