Provider Demographics
NPI:1437516796
Name:BENNETT, KAYLA AMBRIA (PTA)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:AMBRIA
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1917 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-2347
Mailing Address - Country:US
Mailing Address - Phone:606-232-1613
Mailing Address - Fax:
Practice Address - Street 1:12100 PRINCELAND SPUR
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41102-7883
Practice Address - Country:US
Practice Address - Phone:606-928-2963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-18
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA03151225200000X
OHPTA.09313225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant