Provider Demographics
NPI:1497427488
Name:VITRY, KAILYN D (PTA)
Entity Type:Individual
Prefix:
First Name:KAILYN
Middle Name:D
Last Name:VITRY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7000 SPYGLASS CT STE 120
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-7948
Mailing Address - Country:US
Mailing Address - Phone:321-241-6543
Mailing Address - Fax:321-241-6513
Practice Address - Street 1:7000 SPYGLASS CT STE 120
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-7948
Practice Address - Country:US
Practice Address - Phone:321-241-6543
Practice Address - Fax:321-241-6513
Is Sole Proprietor?:No
Enumeration Date:2021-09-29
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA31049225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant