Provider Demographics
NPI:1528846870
Name:MALLARD, KAILEY HOPE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:KAILEY
Middle Name:HOPE
Last Name:MALLARD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:KAILEY
Other - Middle Name:HOPE
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:327 N FERGUSON AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2891
Mailing Address - Country:US
Mailing Address - Phone:931-265-9395
Mailing Address - Fax:
Practice Address - Street 1:1445 E 10TH ST
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2017
Practice Address - Country:US
Practice Address - Phone:931-372-2567
Practice Address - Fax:931-372-2572
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7558225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics