Healthcare Provider Details

I. General information

NPI: 1801307301
Provider Name (Legal Business Name): KAYLA TAYLOR ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2017
Last Update Date: 12/23/2022
Certification Date: 12/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 GREENSBORO DR STE 120
MC LEAN VA
22102-5101
US

IV. Provider business mailing address

1860 TOWN CENTER DR STE 300
RESTON VA
20190-5900
US

V. Phone/Fax

Practice location:
  • Phone: 571-899-3580
  • Fax:
Mailing address:
  • Phone: 703-435-4702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126002474
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: