Healthcare Provider Details

I. General information

NPI: 1235956632
Provider Name (Legal Business Name): KAYLEE HEPPNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2024
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7121 E MOUNT VERNON ST
GLEN SAINT MARY FL
32040-5085
US

IV. Provider business mailing address

165 SCOTLAND YARD BLVD
SAINT JOHNS FL
32259-5913
US

V. Phone/Fax

Practice location:
  • Phone: 904-305-2069
  • Fax:
Mailing address:
  • Phone: 904-605-0614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: