Provider Demographics
NPI:1902558703
Name:FALLON, KAYLEIGH (APRN)
Entity Type:Individual
Prefix:
First Name:KAYLEIGH
Middle Name:
Last Name:FALLON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 SEDGEFIELD PATH S
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-4422
Mailing Address - Country:US
Mailing Address - Phone:386-864-4865
Mailing Address - Fax:
Practice Address - Street 1:60 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-5980
Practice Address - Country:US
Practice Address - Phone:386-864-4865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-23
Last Update Date:2022-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11015792363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner