Provider Demographics
NPI:1114516341
Name:MICHAELS, KILEY DOYLE
Entity Type:Individual
Prefix:
First Name:KILEY
Middle Name:DOYLE
Last Name:MICHAELS
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 1:3801 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-3815
Mailing Address - Country:US
Mailing Address - Phone:203-709-4030
Mailing Address - Fax:203-709-5289
Practice Address - Street 1:3801 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-3815
Practice Address - Country:US
Practice Address - Phone:203-709-4030
Practice Address - Fax:203-709-5289
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-12
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5337363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program