Provider Demographics
NPI:1164840922
Name:VANDERWALL, KAYLA RENE (PA-C)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:RENE
Last Name:VANDERWALL
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 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7430 N SHADELAND AVE STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2036
Practice Address - Country:US
Practice Address - Phone:317-621-0668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-30
Last Update Date:2022-09-01
Deactivation Date:2019-11-06
Deactivation Code:
Reactivation Date:2019-11-19
Provider Licenses
StateLicense IDTaxonomies
IL085007328363AS0400X
IN363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical