Provider Demographics
NPI:1003340464
Name:RICHARDSON, KAYLA (CRNA)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 HARRIS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1531
Mailing Address - Country:US
Mailing Address - Phone:207-754-0477
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-12
Last Update Date:2023-09-11
Deactivation Date:2021-05-27
Deactivation Code:
Reactivation Date:2023-06-09
Provider Licenses
StateLicense IDTaxonomies
MERNA233053367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered