Provider Demographics
NPI:1447994876
Name:SISTRUNK, KALEB (ARNP-BC)
Entity type:Individual
Prefix:
First Name:KALEB
Middle Name:
Last Name:SISTRUNK
Suffix:
Gender:M
Credentials:ARNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9011 LITHIA PINECREST RD
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-2815
Mailing Address - Country:US
Mailing Address - Phone:813-730-3874
Mailing Address - Fax:
Practice Address - Street 1:275 W COCOA BEACH CSWY
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-3529
Practice Address - Country:US
Practice Address - Phone:321-799-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-22
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL657432363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily