=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346717170
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAITLYN PONTRELLI NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2018
-----------------------------------------------------
Last Update Date | 08/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8833 PERIMETER PARK BLVD STE 903
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32216-1120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-503-2429
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3524 CAROLWOOD LN
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32086-4318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-925-2391
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | F343779-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 11019275
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------