Provider Demographics
NPI:1508486630
Name:FIVEASH, KAYLA LYNN (ATC)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:LYNN
Last Name:FIVEASH
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1185 COUNTY ROAD 1000 W
Mailing Address - Street 2:
Mailing Address - City:LINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47441
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1816 HUNTSVILLE HWY
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37334-3787
Practice Address - Country:US
Practice Address - Phone:931-228-5585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23852255A2300X
IN36003559A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer