Healthcare Provider Details

I. General information

NPI: 1548044811
Provider Name (Legal Business Name): YANIRKA JADE KITTRELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2023
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

296 MERCHANTS SQ
DALLAS GA
30132
US

IV. Provider business mailing address

300 INTERNATIONAL PARKWAY, SUITE 200
LAKE MARY FL
32746-3625
US

V. Phone/Fax

Practice location:
  • Phone: 470-391-2300
  • Fax:
Mailing address:
  • Phone: 866-610-0580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22-246661
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: