Provider Demographics
NPI:1982364089
Name:EDMONDSON, KAYLEY E
Entity Type:Individual
Prefix:
First Name:KAYLEY
Middle Name:E
Last Name:EDMONDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAYLEY
Other - Middle Name:E
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22 CREE DR
Mailing Address - Street 2:
Mailing Address - City:LOCK HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17745-2639
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 CREE DR
Practice Address - Street 2:
Practice Address - City:LOCK HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17745-2639
Practice Address - Country:US
Practice Address - Phone:570-748-9377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP010080224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant