Healthcare Provider Details

I. General information

NPI: 1497427488
Provider Name (Legal Business Name): KAILYN D VITRY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2021
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 SPYGLASS CT STE 120
MELBOURNE FL
32940-7948
US

IV. Provider business mailing address

7000 SPYGLASS CT STE 120
MELBOURNE FL
32940-7948
US

V. Phone/Fax

Practice location:
  • Phone: 321-241-6543
  • Fax: 321-241-6513
Mailing address:
  • Phone: 321-241-6543
  • Fax: 321-241-6513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA31049
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: