Provider Demographics
NPI:1730674656
Name:BERTELLI, KATHLEEN RITA
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:RITA
Last Name:BERTELLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3767 GULF BREEZE PKWY
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-3528
Mailing Address - Country:US
Mailing Address - Phone:850-934-3178
Mailing Address - Fax:850-934-1803
Practice Address - Street 1:3767 GULF BREEZE PKWY
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32563-3528
Practice Address - Country:US
Practice Address - Phone:850-934-3178
Practice Address - Fax:850-934-1803
Is Sole Proprietor?:No
Enumeration Date:2018-06-22
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS21975183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist