Provider Demographics
NPI:1376956219
Name:FAZIO, KAYLA BETH (DO)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:BETH
Last Name:FAZIO
Suffix:
Gender:F
Credentials:DO
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 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:769 BLANDING BLVD STE 7
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-8700
Practice Address - Country:US
Practice Address - Phone:904-458-4882
Practice Address - Fax:904-458-4899
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-09
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO 4131207Q00000X
FLOS14284207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021374400Medicaid