Provider Demographics
NPI:1134677222
Name:MALLARE, KAYLA ELLEN
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:ELLEN
Last Name:MALLARE
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 1:14024 OSPREY LINKS RD
Mailing Address - Street 2:APT 323
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-6173
Mailing Address - Country:US
Mailing Address - Phone:586-909-3679
Mailing Address - Fax:
Practice Address - Street 1:1111 W VINE ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4168
Practice Address - Country:US
Practice Address - Phone:586-909-3679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS55488183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist