Healthcare Provider Details

I. General information

NPI: 1669002143
Provider Name (Legal Business Name): KAYLEIGH MARIE MOUAT RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAYLEIGH MARIE TELEMAQUE

II. Dates (important events)

Enumeration Date: 01/23/2020
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 W OAK ST STE 203
ZIONSVILLE IN
46077-3836
US

IV. Provider business mailing address

2705 N LEBANON ST STE 305
LEBANON IN
46052-8622
US

V. Phone/Fax

Practice location:
  • Phone: 317-873-1200
  • Fax: 317-873-1209
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: