Provider Demographics
NPI:1942831169
Name:ELLER, KAYLEIGH DANIELLE
Entity Type:Individual
Prefix:
First Name:KAYLEIGH
Middle Name:DANIELLE
Last Name:ELLER
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 1:147 STEPHANS ROAD
Mailing Address - Street 2:
Mailing Address - City:BOAZ
Mailing Address - State:AL
Mailing Address - Zip Code:35957
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:147 STEPHANS ROAD
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957
Practice Address - Country:US
Practice Address - Phone:256-572-9522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS12710390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program