Provider Demographics
NPI:1376956219
Name:FAZIO, KAYLA BETH (DO)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:BETH
Last Name:FAZIO
Suffix:
Gender:F
Credentials:DO
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Mailing Address - Street 1:PO BOX 746638
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6638
Mailing Address - Country:US
Mailing Address - Phone:904-202-2092
Mailing Address - Fax:904-376-4075
Practice Address - Street 1:769 BLANDING BLVD STE 7
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-8700
Practice Address - Country:US
Practice Address - Phone:904-458-4882
Practice Address - Fax:904-390-7456
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-09
Last Update Date:2024-11-26
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Provider Licenses
StateLicense IDTaxonomies
FLOS14284207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021374400Medicaid