Provider Demographics
NPI:1720800956
Name:ESTRADA, KIANNA JAYLENE
Entity type:Individual
Prefix:
First Name:KIANNA
Middle Name:JAYLENE
Last Name:ESTRADA
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 1:3590 SOUTHERN CROSS LOOP
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-9004
Mailing Address - Country:US
Mailing Address - Phone:407-655-5168
Mailing Address - Fax:
Practice Address - Street 1:3590 SOUTHERN CROSS LOOP
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-9004
Practice Address - Country:US
Practice Address - Phone:407-655-5168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-387864106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician