Provider Demographics
NPI:1154923688
Name:CHAVARRIA, KAYLEE ANN (DPT)
Entity type:Individual
Prefix:
First Name:KAYLEE
Middle Name:ANN
Last Name:CHAVARRIA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 ACACIA ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-3800
Mailing Address - Country:US
Mailing Address - Phone:707-421-2095
Mailing Address - Fax:707-434-9725
Practice Address - Street 1:222 ACACIA ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3800
Practice Address - Country:US
Practice Address - Phone:707-421-2095
Practice Address - Fax:707-434-9725
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299365225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA299365OtherPHYSICAL THERAPY OF CALIFORNIA PT LICENCE