Healthcare Provider Details

I. General information

NPI: 1194680710
Provider Name (Legal Business Name): KAYTLAN AMBER HARGIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 MILL CREEK DR
WINTERVILLE GA
30683-3506
US

IV. Provider business mailing address

119 MILL CREEK DR
WINTERVILLE GA
30683-3506
US

V. Phone/Fax

Practice location:
  • Phone: 661-448-0277
  • Fax:
Mailing address:
  • Phone: 661-448-0277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN333138
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: