Provider Demographics
NPI:1356105712
Name:MITTS, KAITLIN BRIANNA
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:BRIANNA
Last Name:MITTS
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KAITLIN
Other - Middle Name:BRIANNA
Other - Last Name:MITTS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:742 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-2017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:742 JAMES ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2017
Practice Address - Country:US
Practice Address - Phone:315-703-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-07
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY751604163W00000X
NYF406133-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse