Provider Demographics
NPI:1205381829
Name:DEVITA, KIRSTIE
Entity type:Individual
Prefix:
First Name:KIRSTIE
Middle Name:
Last Name:DEVITA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 RACETRACK RD NW
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:339 RACETRACK RD NW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1538
Practice Address - Country:US
Practice Address - Phone:850-374-3187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FL9109709363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant