Provider Demographics
NPI:1346717170
Name:PONTRELLI, KAITLYN (NP)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:PONTRELLI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3524 CAROLWOOD LN
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-4318
Mailing Address - Country:US
Mailing Address - Phone:201-925-2391
Mailing Address - Fax:
Practice Address - Street 1:8833 PERIMETER PARK BLVD STE 903
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1120
Practice Address - Country:US
Practice Address - Phone:904-503-2429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF343779-1363LF0000X
FL11019275363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily