MEDICARE: MISS KAYLA JUSTINE STAFFORD FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	RN267058	GA

General Provider Information

NPI Number	:	1396580643
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS KAYLA JUSTINE STAFFORD FNP-C

Provider Business Mailing Address
First Line	:	388 4TH ST NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30308-2005
Country	:	US
Telephone Number	:	317-600-8717
Fax Number	:

Provider Business Practice Location Address
First Line	:	3422 SIXES RD STE 102
Second Line	:
City	:	CANTON
State	:	GA
Zip	:	30114-9120
Country	:	US
Telephone Number	:	943-202-7670
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2024
Last Update Date	:	06/27/2024

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