Provider Demographics
NPI:1346610524
Name:TAVERNIER, KAYLA PETERSON
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:PETERSON
Last Name:TAVERNIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:P
Other - Last Name:TAVERNIER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:901 W GREENWOOD ST
Mailing Address - Street 2:SUITE 9
Mailing Address - City:ABBEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29620-5717
Mailing Address - Country:US
Mailing Address - Phone:864-366-9681
Mailing Address - Fax:
Practice Address - Street 1:901 W GREENWOOD ST STE 1
Practice Address - Street 2:
Practice Address - City:ABBEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29620-5727
Practice Address - Country:US
Practice Address - Phone:864-366-9681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-01
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPA2419363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant