Provider Demographics
NPI:1477146413
Name:KOONTZ, KAILEY (PA-C)
Entity Type:Individual
Prefix:
First Name:KAILEY
Middle Name:
Last Name:KOONTZ
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 1:2601 S RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-3537
Mailing Address - Country:US
Mailing Address - Phone:386-214-5197
Mailing Address - Fax:
Practice Address - Street 1:2180 W STATE ROAD 434 STE 1124
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-5008
Practice Address - Country:US
Practice Address - Phone:321-972-1741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113974363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant