Healthcare Provider Details

I. General information

NPI: 1255249850
Provider Name (Legal Business Name): BRITTANY KATE SIRIVATH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7910 W JEFFERSON BLVD
FORT WAYNE IN
46804-4159
US

IV. Provider business mailing address

1535 GREYTHORN DR
FORT WAYNE IN
46815-8792
US

V. Phone/Fax

Practice location:
  • Phone: 260-458-3500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: