Provider Demographics
NPI:1306187257
Name:MARINER, KAYLA
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:MARINER
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 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1030 S JEFFERSON ST STE G101
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4418
Practice Address - Country:US
Practice Address - Phone:540-224-4360
Practice Address - Fax:540-224-4357
Is Sole Proprietor?:No
Enumeration Date:2013-03-01
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1080122133V00000X
NCL004539133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered