Provider Demographics
NPI:1396161824
Name:ANTHONY, KAYLA
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:ANTHONY
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 1:586 SMITHTOWN AVE
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-4916
Mailing Address - Country:US
Mailing Address - Phone:631-589-4799
Mailing Address - Fax:
Practice Address - Street 1:335 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-1143
Practice Address - Country:US
Practice Address - Phone:631-589-8060
Practice Address - Fax:631-589-0908
Is Sole Proprietor?:No
Enumeration Date:2014-03-07
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3545348174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator