Provider Demographics
NPI:1184321168
Name:GORHAM, KAYLA NIQUEL
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:NIQUEL
Last Name:GORHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298-5064
Mailing Address - Country:US
Mailing Address - Phone:804-828-9095
Mailing Address - Fax:804-828-9095
Practice Address - Street 1:1851 MACGREGOR DOWNS RD APT R
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5925
Practice Address - Country:US
Practice Address - Phone:252-737-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-10
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014194401223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223G0001XDental ProvidersDentistGeneral Practice