Provider Demographics
NPI:1003698861
Name:MCNULTY, KAYLA MAUREEN
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:MAUREEN
Last Name:MCNULTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 CANTABRIA TRL
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-1588
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6305 INITIATIVE BLVD.
Practice Address - Street 2:STE 101
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34240
Practice Address - Country:US
Practice Address - Phone:941-202-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11028500363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner