Healthcare Provider Details

I. General information

NPI: 1639733009
Provider Name (Legal Business Name): TAYLER JADE HAYMAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2019
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MAR WALT DR
FORT WALTON BEACH FL
32547-6708
US

IV. Provider business mailing address

201 LAKESIDE LN
MARY ESTHER FL
32569-1460
US

V. Phone/Fax

Practice location:
  • Phone: 850-862-1111
  • Fax:
Mailing address:
  • Phone: 812-216-3474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06005861A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA31509
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: