Provider Demographics
NPI:1942747985
Name:HARRELL, KAYLYN
Entity Type:Individual
Prefix:
First Name:KAYLYN
Middle Name:
Last Name:HARRELL
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:PO BOX 243
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:39813-0243
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2109 N PATTERSON ST
Practice Address - Street 2:SUITE #A
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2990
Practice Address - Country:US
Practice Address - Phone:229-247-5225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-29
Last Update Date:2017-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003756225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant