Healthcare Provider Details

I. General information

NPI: 1477146413
Provider Name (Legal Business Name): KAILEY KOONTZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2021
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16890 US HIGHWAY 441
MOUNT DORA FL
32757-6705
US

IV. Provider business mailing address

16890 US HIGHWAY 441
MOUNT DORA FL
32757-6705
US

V. Phone/Fax

Practice location:
  • Phone: 352-729-2514
  • Fax: 352-729-2613
Mailing address:
  • Phone: 386-214-5197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9113974
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: