Provider Demographics
NPI:1811321516
Name:HARGRAVES, KYLA NICOLE (PA)
Entity type:Individual
Prefix:
First Name:KYLA
Middle Name:NICOLE
Last Name:HARGRAVES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1210
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34133-1210
Mailing Address - Country:US
Mailing Address - Phone:407-895-8818
Mailing Address - Fax:407-291-3800
Practice Address - Street 1:875 OUTER RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32814-6652
Practice Address - Country:US
Practice Address - Phone:407-895-8818
Practice Address - Fax:407-291-3800
Is Sole Proprietor?:No
Enumeration Date:2013-08-29
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009606800Medicaid