Provider Demographics
NPI:1093475154
Name:DUGHLAS, KAITLIN (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:DUGHLAS
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15115 LEROY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2618
Mailing Address - Country:US
Mailing Address - Phone:734-771-8017
Mailing Address - Fax:
Practice Address - Street 1:15350 TRENTON RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2027
Practice Address - Country:US
Practice Address - Phone:734-283-4616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704338496363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics