Healthcare Provider Details

I. General information

NPI: 1659955409
Provider Name (Legal Business Name): KAYLA MARIE SUWANARAT PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2021
Last Update Date: 05/07/2021
Certification Date: 05/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 FORSYTHE ST
FAYETTEVILLE NC
28303-5454
US

IV. Provider business mailing address

42 WALNUT GROVE DR
BUNNLEVEL NC
28323-9158
US

V. Phone/Fax

Practice location:
  • Phone: 910-829-0100
  • Fax:
Mailing address:
  • Phone: 190-440-2078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: