Healthcare Provider Details

I. General information

NPI: 1285529875
Provider Name (Legal Business Name): KAITLYN MACKENZIE BLACKBURN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2025
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2519 S ORANGE AVE
ORLANDO FL
32806-4545
US

IV. Provider business mailing address

2519 S ORANGE AVE
ORLANDO FL
32806-4545
US

V. Phone/Fax

Practice location:
  • Phone: 407-648-1697
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPTAT34078
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: