Healthcare Provider Details

I. General information

NPI: 1669092789
Provider Name (Legal Business Name): KAYLIN MAE KLUVI CSTFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2020
Last Update Date: 09/18/2021
Certification Date: 09/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 NOWELL LOOP
DELAND FL
32724-9724
US

IV. Provider business mailing address

504 NOWELL LOOP
DELAND FL
32724-9724
US

V. Phone/Fax

Practice location:
  • Phone: 386-212-0509
  • Fax:
Mailing address:
  • Phone: 386-212-0509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number205606
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number122409
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: