Provider Demographics
NPI:1083284004
Name:KICKLIGHTER, SHAYLA MAE (PA-C)
Entity Type:Individual
Prefix:
First Name:SHAYLA
Middle Name:MAE
Last Name:KICKLIGHTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12222 N CENTRAL EXPY STE 420
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-3825
Mailing Address - Country:US
Mailing Address - Phone:972-985-2797
Mailing Address - Fax:972-985-4797
Practice Address - Street 1:12222 N CENTRAL EXPY STE 420
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-3825
Practice Address - Country:US
Practice Address - Phone:972-985-2797
Practice Address - Fax:972-985-4797
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA15826363A00000X
SC4016363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty