Healthcare Provider Details

I. General information

NPI: 1801681242
Provider Name (Legal Business Name): KAITLIN FOGARTY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4220 VALLEY RIDGE BLVD STE 106
PONTE VEDRA FL
32081-5173
US

IV. Provider business mailing address

6385 MCGINNIS FERRY RD STE 201
JOHNS CREEK GA
30005-3672
US

V. Phone/Fax

Practice location:
  • Phone: 904-217-0361
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR011389
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH15513
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: