Provider Demographics
NPI:1134628498
Name:SPALLA, KATHLEEN L (PHYSICIAN ASSISTANCE)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:L
Last Name:SPALLA
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANCE
Other - Prefix:MRS
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:AEY, HARPER, BERRY, WINEBURNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANCE
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6063
Mailing Address - Fax:904-539-4091
Practice Address - Street 1:6665 PENSACOLA BLVD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32505-1705
Practice Address - Country:US
Practice Address - Phone:850-416-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111078363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1134628498Medicaid