Provider Demographics
NPI:1205669694
Name:TATUM, KAYLA DIANE
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:DIANE
Last Name:TATUM
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 1:110 PINYON PINE CIR APT 6003
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-5687
Mailing Address - Country:US
Mailing Address - Phone:912-850-0183
Mailing Address - Fax:
Practice Address - Street 1:110 PINYON PINE CIR APT 6003
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-5687
Practice Address - Country:US
Practice Address - Phone:912-850-0183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program