Provider Demographics
NPI:1164559415
Name:KITTLESON, JEANIE MARIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JEANIE
Middle Name:MARIE
Last Name:KITTLESON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 HANLEY WAY
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-5387
Mailing Address - Country:US
Mailing Address - Phone:252-258-2164
Mailing Address - Fax:
Practice Address - Street 1:ST ROSE DOMINICAN DE LIMA
Practice Address - Street 2:102 E LAKE MEAD PKWY
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015
Practice Address - Country:US
Practice Address - Phone:702-616-4600
Practice Address - Fax:702-616-4311
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA833363AM0700X, 363AS0400X, 363A00000X
FLPA9114559363AM0700X
NV363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100503035Medicaid
NVQ12389Medicare UPIN
NV39086Medicare PIN