Basic Information
| Provider Information | |||||||||
| NPI: | 1134709884 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KACZKA | ||||||||
| FirstName: | KAITLYN | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | MSN, APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 WELLS RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320732982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042826331 | ||||||||
| FaxNumber: | 9046191080 | ||||||||
| Practice Location | |||||||||
| Address1: | 7855 ARGYLE FOREST BLVD STE 601 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322447704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047783389 | ||||||||
| FaxNumber: | 9047783395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2021 | ||||||||
| LastUpdateDate: | 06/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | APRN11016444 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LF0000X | APRN11016444 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.