1295292381 NPI number — JONNI E KITCHELL

Table of content: JONNI E KITCHELL (NPI 1295292381)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295292381 NPI number — JONNI E KITCHELL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KITCHELL
Provider First Name:
JONNI
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295292381
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 8TH AVE W STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALMETTO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34221-4737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-776-4000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5325 26TH ST W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRADENTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34207-3012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-494-1242
Provider Business Practice Location Address Fax Number:
863-491-0466
Provider Enumeration Date:
02/25/2019

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: 1041C0700X , with the licence number:  SW15022 , 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)

  • Identifier: 102914300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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