1952835175 NPI number — KAYLA FORRESTER

Table of content: KAYLA FORRESTER (NPI 1952835175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952835175 NPI number — KAYLA FORRESTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORRESTER
Provider First Name:
KAYLA
Provider Middle Name:
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:
1952835175
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 DAVIS BLVD STE 308
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33606-3438
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-250-2506
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 DAVIS BLVD STE 308
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-250-2506
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/13/2017

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: 207QH0002X , with the licence number:  ME160771 , 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: 6Y6C8 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 118234000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".