Provider Demographics
NPI:1396258596
Name:ANDERSON, KAYLA ASTIN
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:ASTIN
Last Name:ANDERSON
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 1:47 MAPLEDALE AVE
Mailing Address - Street 2:
Mailing Address - City:SUCCASUNNA
Mailing Address - State:NJ
Mailing Address - Zip Code:07876-1643
Mailing Address - Country:US
Mailing Address - Phone:973-896-5358
Mailing Address - Fax:
Practice Address - Street 1:47 MAPLEDALE AVE
Practice Address - Street 2:
Practice Address - City:SUCCASUNNA
Practice Address - State:NJ
Practice Address - Zip Code:07876-1643
Practice Address - Country:US
Practice Address - Phone:973-896-5358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT002436002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer