Provider Demographics
NPI:1003208125
Name:BORNHAUSER, KAYLEIGH (PHARMD)
Entity Type:Individual
Prefix:
First Name:KAYLEIGH
Middle Name:
Last Name:BORNHAUSER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:MS 3000
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-5005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 TRIEBLE AVE
Practice Address - Street 2:
Practice Address - City:BALLSTON SPA
Practice Address - State:NY
Practice Address - Zip Code:12020-6010
Practice Address - Country:US
Practice Address - Phone:518-885-4672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI059161183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist