=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194489708
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEYADA LAURAY MA91822
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2021
-----------------------------------------------------
Last Update Date | 10/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 811 N MARKET ST
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-510-8060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9943 ROSEWOOD GLEN LN
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32219-4331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-729-7924
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MA91822
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------