MEDICARE: ALISSA LAUREN KITCHEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396215141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALISSA LAUREN KITCHEN

Provider Business Mailing Address
First Line	:	10965 CLARENDON ST
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33913-8562
Country	:	US
Telephone Number	:	573-673-2754
Fax Number	:

Provider Business Practice Location Address
First Line	:	2010 59TH ST W STE 4200
Second Line	:
City	:	BRADENTON
State	:	FL
Zip	:	34209-4687
Country	:	US
Telephone Number	:	941-794-3999
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2018
Last Update Date	:	12/04/2018

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Directions to “ ALISSA LAUREN KITCHEN ” Practice Location

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