Provider Demographics
NPI:1780720631
Name:KITELYNN, STEPHANIE MILLER (MSOTRL)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MILLER
Last Name:KITELYNN
Suffix:
Gender:F
Credentials:MSOTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4916 98TH WAY N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33708-3645
Mailing Address - Country:US
Mailing Address - Phone:727-678-1238
Mailing Address - Fax:
Practice Address - Street 1:801 6TH ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4816
Practice Address - Country:US
Practice Address - Phone:727-767-4257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT9746225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL890170800Medicaid