Healthcare Provider Details

I. General information

NPI: 1043079031
Provider Name (Legal Business Name): KAYLA LYNN FARNHAM CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2024
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 POPLAR DR
PETERSBURG VA
23805-9367
US

IV. Provider business mailing address

7781 CHEATHAMS RD
AMELIA COURT HOUSE VA
23002-2803
US

V. Phone/Fax

Practice location:
  • Phone: 804-733-6874
  • Fax:
Mailing address:
  • Phone: 804-212-8095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: