Provider Demographics
NPI:1619379716
Name:JANUSKO, KAYLEE NELSON
Entity Type:Individual
Prefix:
First Name:KAYLEE
Middle Name:NELSON
Last Name:JANUSKO
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 1:70 LINDSEY LN
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-1635
Mailing Address - Country:US
Mailing Address - Phone:912-510-6104
Mailing Address - Fax:912-882-6137
Practice Address - Street 1:70 LINDSEY LN
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-1635
Practice Address - Country:US
Practice Address - Phone:912-510-6104
Practice Address - Fax:912-882-6137
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT29696225100000X
GAPT0118942251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist