Provider Demographics
NPI:1619466760
Name:SMALL, KYJANA
Entity Type:Individual
Prefix:
First Name:KYJANA
Middle Name:
Last Name:SMALL
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 1:5816 CREEKSIDE SANDS LN
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-3645
Mailing Address - Country:US
Mailing Address - Phone:909-856-9564
Mailing Address - Fax:
Practice Address - Street 1:5816 CREEKSIDE SANDS LN
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-3645
Practice Address - Country:US
Practice Address - Phone:909-856-9564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner