Healthcare Provider Details

I. General information

NPI: 1003494808
Provider Name (Legal Business Name): KAITLYN LYFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2021
Last Update Date: 04/01/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 OAKLEY AVE
LYNCHBURG VA
24501
US

IV. Provider business mailing address

302 OAKLEY AVE
LYNCHBURG VA
24501
US

V. Phone/Fax

Practice location:
  • Phone: 434-610-7087
  • Fax: 434-660-0699
Mailing address:
  • Phone: 434-610-7087
  • Fax: 434-660-0699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-20-43716
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: