Provider Demographics
NPI:1932866043
Name:ANDERSON, KAYLA
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:ANDERSON
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 1:92 GORDON OAKS WAY
Mailing Address - Street 2:
Mailing Address - City:MORELAND
Mailing Address - State:GA
Mailing Address - Zip Code:30259-2854
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:122 GORDON COMMERCIAL DR STE C
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-5754
Practice Address - Country:US
Practice Address - Phone:706-845-4045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN248945163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse