1114525870 NPI number — KAYLA JEAN ABBOTT OTR/L

Table of content: KAYLA JEAN ABBOTT OTR/L (NPI 1114525870)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114525870 NPI number — KAYLA JEAN ABBOTT OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ABBOTT
Provider First Name:
KAYLA
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
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:
1114525870
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
526 SCRUB JAY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT AUGUSTINE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32092-1751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-319-3910
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5150 PALM VALLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PONTE VEDRA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32082-4629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-382-9790
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/15/2020

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: 225X00000X , with the licence number:  OT21297 , 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: 108622100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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