Healthcare Provider Details

I. General information

NPI: 1275350969
Provider Name (Legal Business Name): KAYLA BRIANNA ANTEQUERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2024
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 W BASS ST
KISSIMMEE FL
34741-5001
US

IV. Provider business mailing address

13518 FALLS PARK WAY
ORLANDO FL
32824-4384
US

V. Phone/Fax

Practice location:
  • Phone: 321-445-1287
  • Fax:
Mailing address:
  • Phone: 347-869-4693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSI7054
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: