Healthcare Provider Details

I. General information

NPI: 1457149221
Provider Name (Legal Business Name): MS. MARY BROOKE CALITRI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2025
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 E VENICE AVE
VENICE FL
34292-3190
US

IV. Provider business mailing address

2675 WINKLER AVE STE 200
FORT MYERS FL
33901-9328
US

V. Phone/Fax

Practice location:
  • Phone: 941-483-9760
  • Fax: 941-483-9775
Mailing address:
  • Phone: 941-483-9760
  • Fax: 941-483-9775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9120861
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: