Healthcare Provider Details

I. General information

NPI: 1659106250
Provider Name (Legal Business Name): ASHLYN KEZIAH MSPH, LCGC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2024
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 W DR MARTIN LUTHER KING JR BLVD # MS 3105
TAMPA FL
33607-6307
US

IV. Provider business mailing address

342 46TH AVE S
SAINT PETERSBURG FL
33705-4525
US

V. Phone/Fax

Practice location:
  • Phone: 813-870-4238
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License NumberGC785
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: