Provider Demographics
NPI:1093495129
Name:VEGA, KYLYNN RAEGAN (OTD, OTR)
Entity Type:Individual
Prefix:
First Name:KYLYNN
Middle Name:RAEGAN
Last Name:VEGA
Suffix:
Gender:F
Credentials:OTD, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 843
Mailing Address - Street 2:
Mailing Address - City:TAHOKA
Mailing Address - State:TX
Mailing Address - Zip Code:79373-0843
Mailing Address - Country:US
Mailing Address - Phone:806-441-8085
Mailing Address - Fax:
Practice Address - Street 1:1808 N. 3RD ST
Practice Address - Street 2:
Practice Address - City:TAHOKA
Practice Address - State:TX
Practice Address - Zip Code:79373
Practice Address - Country:US
Practice Address - Phone:806-441-8085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX123771225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist