Provider Demographics
NPI:1033616875
Name:EVANS, KAYLIE DINNING
Entity Type:Individual
Prefix:
First Name:KAYLIE
Middle Name:DINNING
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAYLIE
Other - Middle Name:ELAINE
Other - Last Name:DINNING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14183 MARK ST
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-5987
Mailing Address - Country:US
Mailing Address - Phone:225-485-6158
Mailing Address - Fax:
Practice Address - Street 1:3452 LAKE LYNDA DR STE 200
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-1481
Practice Address - Country:US
Practice Address - Phone:800-774-7785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-09
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOTR-1331225X00000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117899OtherOT LICENSE