Provider Demographics
NPI:1780497784
Name:LONERGAN, CAITLIN MARIE
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:MARIE
Last Name:LONERGAN
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 1:13764 SHADY WOODS ST N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-4822
Mailing Address - Country:US
Mailing Address - Phone:406-599-6789
Mailing Address - Fax:
Practice Address - Street 1:13764 SHADY WOODS ST N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-4822
Practice Address - Country:US
Practice Address - Phone:406-599-6789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-31
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9119760363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant