Provider Demographics
NPI:1619320199
Name:SEBASTIAN, KAYLEY
Entity Type:Individual
Prefix:
First Name:KAYLEY
Middle Name:
Last Name:SEBASTIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 E TRADE ST
Mailing Address - Street 2:SUITE E-186
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2404
Mailing Address - Country:US
Mailing Address - Phone:704-971-1254
Mailing Address - Fax:
Practice Address - Street 1:210 E TRADE ST
Practice Address - Street 2:SUITE E-186
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-2404
Practice Address - Country:US
Practice Address - Phone:704-971-1254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26257183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist