Provider Demographics
NPI:1982472999
Name:LEBRON, KAYLA MARIE
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:MARIE
Last Name:LEBRON
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 1:3204 SKYNIGHT DR
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-5117
Mailing Address - Country:US
Mailing Address - Phone:850-902-4241
Mailing Address - Fax:
Practice Address - Street 1:928 N FERDON BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-1706
Practice Address - Country:US
Practice Address - Phone:850-902-4241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-19
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMM101126225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist