Provider Demographics
NPI:1063885028
Name:KAJDASZ, KERRY
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:KAJDASZ
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 1:351 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-1714
Mailing Address - Country:US
Mailing Address - Phone:941-800-7133
Mailing Address - Fax:
Practice Address - Street 1:380 OLD ENGLEWOOD RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34223-4020
Practice Address - Country:US
Practice Address - Phone:941-800-7133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-12
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP3606171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist