=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356011696
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAYSHAUN HARRIS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2021
-----------------------------------------------------
Last Update Date | 09/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10574 LAKE HOLLOW LN
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32257-3788
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-866-9063
-----------------------------------------------------
Fax | 904-866-9063
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10574 LAKE HOLLOW LN
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32257-3788
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-866-9063
-----------------------------------------------------
Fax | 904-866-9063
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376J00000X
-----------------------------------------------------
Taxonomy Name | Homemaker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 372500000X
-----------------------------------------------------
Taxonomy Name | Chore Provider
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------