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General NPI Number Information
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NPI Number | 1336703461
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Entity Type | Individual
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Provider Name | AYESHA FALAK KIETZMAN PA
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Gender | Female
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Dates
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Enumeration Date | 04/24/2019
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Last Update Date | 06/14/2019
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Provider Practice Location Address
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Address Line | 13944 LAKESHORE BLVD STE C
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City | HUDSON
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State | FL
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Zip | 34667-1431
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Country | US
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Telephone | 727-605-0252
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Fax |
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Provider Business Mailing Address
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Address Line | 14690 SPRING HILL DR STE 305
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City | SPRING HILL
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State | FL
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Zip | 34609-8102
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Country | US
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Telephone | 352-277-5348
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Fax | 352-606-2857
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA9112195
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License Number State | FL
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