Provider Demographics
NPI:1407575335
Name:FOMIN, KAYLA MICHELLE (OMT)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:MICHELLE
Last Name:FOMIN
Suffix:
Gender:F
Credentials:OMT
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:
Other - Last Name:ZAUBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:136 HOMEPLACE DR
Mailing Address - Street 2:
Mailing Address - City:MT HOLLY
Mailing Address - State:NC
Mailing Address - Zip Code:28120-9660
Mailing Address - Country:US
Mailing Address - Phone:803-820-1607
Mailing Address - Fax:
Practice Address - Street 1:136 HOMEPLACE DR
Practice Address - Street 2:
Practice Address - City:MT HOLLY
Practice Address - State:NC
Practice Address - Zip Code:28120-9660
Practice Address - Country:US
Practice Address - Phone:803-820-1607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11570124Q00000X
171400000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No124Q00000XDental ProvidersDental Hygienist
No171400000XOther Service ProvidersHealth & Wellness Coach