Provider Demographics
NPI:1053749291
Name:FENECH, KAYLA (MA, CCC/SLP)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:FENECH
Suffix:
Gender:F
Credentials:MA, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 E LEONARD ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-4861
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5308 STEWART ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-4736
Practice Address - Country:US
Practice Address - Phone:850-981-3506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3904154235Z00000X
FLSA15213235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020189600Medicaid