1508611260 NPI number — KAITLEN HENNESSEY MARTELL PA-C

Table of content: KAITLEN HENNESSEY MARTELL PA-C (NPI 1508611260)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508611260 NPI number — KAITLEN HENNESSEY MARTELL PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTELL
Provider First Name:
KAITLEN
Provider Middle Name:
HENNESSEY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HENNESSEY
Provider Other First Name:
KAITLEN
Provider Other Middle Name:
MARY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508611260
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5518 ATLANTIC AVE APT 208
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DELRAY BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33484-8595
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-495-7856
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16215 S JOG RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DELRAY BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33446-2387
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-303-0013
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/17/2024

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA9118734 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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