Provider Demographics
NPI:1669095675
Name:CWIKLA, KATHLEEN (OD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:CWIKLA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 LYNNDALE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-5230
Mailing Address - Country:US
Mailing Address - Phone:042-615-7419
Mailing Address - Fax:
Practice Address - Street 1:1523 SADLER RD
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4467
Practice Address - Country:US
Practice Address - Phone:904-261-5955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-26
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5785152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist