Provider Demographics
NPI:1821878638
Name:LEBORGNE, KAYLEE RAE (PA-C)
Entity Type:Individual
Prefix:
First Name:KAYLEE
Middle Name:RAE
Last Name:LEBORGNE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-1612
Mailing Address - Fax:239-343-4229
Practice Address - Street 1:13685 DOCTORS WAY STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4337
Practice Address - Country:US
Practice Address - Phone:239-343-1612
Practice Address - Fax:239-343-4229
Is Sole Proprietor?:No
Enumeration Date:2023-10-02
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL91179632086S0127X
FLPA9117963363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL119846700Medicaid