Provider Demographics
NPI:1053865212
Name:INMAN, KAILEY C (PA-C)
Entity Type:Individual
Prefix:
First Name:KAILEY
Middle Name:C
Last Name:INMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAILEY
Other - Middle Name:C
Other - Last Name:FORMELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:717 W MORELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-2432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:717 W MORELAND BLVD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-2432
Practice Address - Country:US
Practice Address - Phone:262-542-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-04
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3785 - 23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant