Provider Demographics
NPI:1073009353
Name:SPRAGUE, KAITLYN ROSE (PA)
Entity Type:Individual
Prefix:MRS
First Name:KAITLYN
Middle Name:ROSE
Last Name:SPRAGUE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S AUSTRALIAN AVE # 422
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-5004
Mailing Address - Country:US
Mailing Address - Phone:561-331-8800
Mailing Address - Fax:561-331-8074
Practice Address - Street 1:560 VILLAGE BLVD SUITE #150
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409
Practice Address - Country:US
Practice Address - Phone:561-331-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-10
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111136363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant