Provider Demographics
NPI:1366279986
Name:PROVENCE, KAYLEIGH
Entity type:Individual
Prefix:
First Name:KAYLEIGH
Middle Name:
Last Name:PROVENCE
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 1:2720 HONEY BEE LN
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-3840
Mailing Address - Country:US
Mailing Address - Phone:870-316-3760
Mailing Address - Fax:
Practice Address - Street 1:2720 HONEY BEE LN
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-3840
Practice Address - Country:US
Practice Address - Phone:870-316-3760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care