Provider Demographics
NPI:1093448839
Name:SHANLE, KAITLYN
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:SHANLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 ALGONQUIN CIR
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:MO
Mailing Address - Zip Code:63050-4411
Mailing Address - Country:US
Mailing Address - Phone:314-922-4813
Mailing Address - Fax:
Practice Address - Street 1:5 ALGONQUIN CIR
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:MO
Practice Address - Zip Code:63050-4411
Practice Address - Country:US
Practice Address - Phone:314-922-4813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-08
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2023049010363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program