Provider Demographics
NPI:1144299579
Name:KRONENTHAL, GRETCHEN L (PA-C)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:L
Last Name:KRONENTHAL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:GRETCHEN
Other - Middle Name:L
Other - Last Name:KIEFFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:14690 SPRING HILL DR STE 305
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-8102
Mailing Address - Country:US
Mailing Address - Phone:352-277-5348
Mailing Address - Fax:352-606-2857
Practice Address - Street 1:9030 W FORT ISLAND TRL STE 1
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-8011
Practice Address - Country:US
Practice Address - Phone:352-228-8906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0030753363AM0700X
FLPA 9104147363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000725800Medicaid
VT9000245Medicaid
FLAD949WMedicare PIN
VTAP2554Medicare ID - Type Unspecified
FL000725800Medicaid