Provider Demographics
NPI:1356961114
Name:MAZZANTI, KAYLA BROOKE (CRNA)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:BROOKE
Last Name:MAZZANTI
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11001 EXECUTIVE CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4393
Mailing Address - Country:US
Mailing Address - Phone:501-812-7215
Mailing Address - Fax:501-812-7207
Practice Address - Street 1:1401 SCOTT ST APT 411
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-5083
Practice Address - Country:US
Practice Address - Phone:870-733-7033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-22
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR390200000X
AR125824367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program