Provider Demographics
NPI:1457537821
Name:EVANS, KAYLA MYKEYYA (LMBT)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:MYKEYYA
Last Name:EVANS
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2209 GREEN PEACH RD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-9175
Mailing Address - Country:US
Mailing Address - Phone:803-285-2742
Mailing Address - Fax:
Practice Address - Street 1:112 N WOODLAND DR STE B
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-4787
Practice Address - Country:US
Practice Address - Phone:803-285-2742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2008-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5416225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist