Provider Demographics
NPI:1154437572
Name:WOLLITZ, KATHERINE LOUISE (PAC)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:LOUISE
Last Name:WOLLITZ
Suffix:
Gender:F
Credentials:PAC
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 61148
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32236-1148
Mailing Address - Country:US
Mailing Address - Phone:904-308-3696
Mailing Address - Fax:904-308-3697
Practice Address - Street 1:1201 MONUMENT RD
Practice Address - Street 2:STE 201
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225
Practice Address - Country:US
Practice Address - Phone:904-727-5151
Practice Address - Fax:904-727-3887
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2462207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE4782XMedicare PIN
P17438Medicare UPIN