Provider Demographics
NPI:1851015754
Name:FAC, KAYLA
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:FAC
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 1:146 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:CASTLETON
Mailing Address - State:VT
Mailing Address - Zip Code:05735-9257
Mailing Address - Country:US
Mailing Address - Phone:860-483-0622
Mailing Address - Fax:
Practice Address - Street 1:146 SOUTH ST
Practice Address - Street 2:
Practice Address - City:CASTLETON
Practice Address - State:VT
Practice Address - Zip Code:05735-9257
Practice Address - Country:US
Practice Address - Phone:860-483-0622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1794092782255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer