Healthcare Provider Details

I. General information

NPI: 1093476731
Provider Name (Legal Business Name): CAITLYN TAYLOR PRIMAVERA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2022
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3021 LYNNHAVEN DR
VIRGINIA BEACH VA
23451-1112
US

IV. Provider business mailing address

3021 LYNNHAVEN DR
VIRGINIA BEACH VA
23451-1112
US

V. Phone/Fax

Practice location:
  • Phone: 850-896-7207
  • Fax:
Mailing address:
  • Phone: 850-896-7207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0009814
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110009756
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: