Healthcare Provider Details

I. General information

NPI: 1316718059
Provider Name (Legal Business Name): JACQUELYN GRACE TRITTO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2024
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 6TH AVE S
SAINT PETERSBURG FL
33701-4634
US

IV. Provider business mailing address

501 6TH AVE S
SAINT PETERSBURG FL
33701-4634
US

V. Phone/Fax

Practice location:
  • Phone: 727-898-7451
  • Fax:
Mailing address:
  • Phone: 347-630-1642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9118329
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: