Provider Demographics
NPI:1467793133
Name:KITCHENS, CARLY ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ELIZABETH
Last Name:KITCHENS
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 1:2209 NE 17TH TER
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33305-2415
Mailing Address - Country:US
Mailing Address - Phone:786-346-8423
Mailing Address - Fax:
Practice Address - Street 1:2500 E HALLANDALE BEACH BLVD
Practice Address - Street 2:SUITE PH2
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-4834
Practice Address - Country:US
Practice Address - Phone:954-456-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-06
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107089363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4807363OtherAETNA
FLPA9107089OtherPA LICENSE
FLP965151OtherOPTIMUM
FLP01467310OtherRR MEDICARE
FLY0QL1OtherBCBS
FLP1027784OtherFREEDOM
FL1228580OtherWELLCARE
FL4601154OtherCIGNA
FL398644OtherAVMED
FLP01467310OtherRR MEDICARE