Provider Demographics
NPI:1073398525
Name:ANDERSON, KAYLA JEAN (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:JEAN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:JEAN
Other - Last Name:KOTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8590 SAINT LUKES DR
Mailing Address - Street 2:
Mailing Address - City:BEARDSTOWN
Mailing Address - State:IL
Mailing Address - Zip Code:62618-8398
Mailing Address - Country:US
Mailing Address - Phone:217-323-2242
Mailing Address - Fax:
Practice Address - Street 1:8590 SAINT LUKES DR
Practice Address - Street 2:
Practice Address - City:BEARDSTOWN
Practice Address - State:IL
Practice Address - Zip Code:62618-8398
Practice Address - Country:US
Practice Address - Phone:217-323-2242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID209027939363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics