Provider Demographics
NPI:1164815809
Name:MACINNIS, KAYLA (MS, ATC, EMT-B)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:MACINNIS
Suffix:
Gender:F
Credentials:MS, ATC, EMT-B
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 SOUTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-7994
Mailing Address - Country:US
Mailing Address - Phone:203-744-1510
Mailing Address - Fax:203-744-1275
Practice Address - Street 1:73 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810
Practice Address - Country:US
Practice Address - Phone:203-744-1510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-05
Last Update Date:2019-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT22885146N00000X
CT10842255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT22885OtherEMT-B
CT2000018481OtherNATIONAL ATHLETIC TRAINERS ASSOCIATION - BOARD OF CERTIFICATION