Healthcare Provider Details

I. General information

NPI: 1265153779
Provider Name (Legal Business Name): KAYELLA LYNNE SAN MIGUEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2022
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 LYNNHAVEN PKWY
VIRGINIA BEACH VA
23452-7332
US

IV. Provider business mailing address

3295 N ARLINGTON HEIGHTS RD STE 107
ARLINGTON HEIGHTS IL
60004-1588
US

V. Phone/Fax

Practice location:
  • Phone: 206-224-5001
  • Fax:
Mailing address:
  • Phone: 224-206-5001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0133003495
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: