Healthcare Provider Details

I. General information

NPI: 1134628498
Provider Name (Legal Business Name): KATHLEEN L SPALLA PHYSICIAN ASSISTANCE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHLEEN AEY, HARPER, BERRY, WINEBURNER PHYSICIAN ASSISTANCE

II. Dates (important events)

Enumeration Date: 02/01/2018
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6665 PENSACOLA BLVD
PENSACOLA FL
32505-1705
US

IV. Provider business mailing address

4205 BELFORT RD STE 4015
JACKSONVILLE FL
32216-3623
US

V. Phone/Fax

Practice location:
  • Phone: 850-416-2000
  • Fax:
Mailing address:
  • Phone: 904-450-6063
  • Fax: 904-539-4091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9111078
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: