Provider Demographics
NPI:1093217226
Name:EWING, KAYLA DYNISE
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:DYNISE
Last Name:EWING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 RICHTER AVE
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76711-1954
Mailing Address - Country:US
Mailing Address - Phone:254-424-6207
Mailing Address - Fax:
Practice Address - Street 1:2201 RICHTER AVE
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76711-1954
Practice Address - Country:US
Practice Address - Phone:254-424-6207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-04
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT82352255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10053642703OtherSCOTT & WHITE HMO