Healthcare Provider Details

I. General information

NPI: 1598627341
Provider Name (Legal Business Name): KAYLA SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E GRANADA BLVD STE 1
ORMOND BEACH FL
32176-6634
US

IV. Provider business mailing address

115 E GRANADA BLVD STE 1
ORMOND BEACH FL
32176-6634
US

V. Phone/Fax

Practice location:
  • Phone: 386-265-1441
  • Fax: 386-265-4066
Mailing address:
  • Phone: 386-265-1441
  • Fax: 386-265-4066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11043953
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: