Provider Demographics
NPI:1902220288
Name:BAKER, KAVONTAYE (DPT)
Entity Type:Individual
Prefix:
First Name:KAVONTAYE
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 EARNEST BARKLEY ST
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:FL
Mailing Address - Zip Code:32332-2050
Mailing Address - Country:US
Mailing Address - Phone:850-510-6784
Mailing Address - Fax:
Practice Address - Street 1:191 EARNEST BARKLEY ST
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:FL
Practice Address - Zip Code:32332-2050
Practice Address - Country:US
Practice Address - Phone:850-510-6784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-07
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT28786225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist