Healthcare Provider Details

I. General information

NPI: 1104267749
Provider Name (Legal Business Name): KATHLEEN MCKENNA RUHLIN PRIMM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2013
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14546 OLD SAINT AUGUSTINE RD STE 407
JACKSONVILLE FL
32258-5473
US

IV. Provider business mailing address

11945 SAN JOSE BLVD STE 300
JACKSONVILLE FL
32223-1627
US

V. Phone/Fax

Practice location:
  • Phone: 904-262-3372
  • Fax: 904-262-3306
Mailing address:
  • Phone: 904-396-1725
  • Fax: 904-396-4893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number50.003862
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9109278
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: