Provider Demographics
NPI:1225683691
Name:FETLA, KAIRA LEE
Entity Type:Individual
Prefix:
First Name:KAIRA
Middle Name:LEE
Last Name:FETLA
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 1:1001 WEST ST
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:NY
Mailing Address - Zip Code:13619-9776
Mailing Address - Country:US
Mailing Address - Phone:315-493-1340
Mailing Address - Fax:
Practice Address - Street 1:1001 WEST ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619-9703
Practice Address - Country:US
Practice Address - Phone:315-493-1340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-02
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT014186225100000X
NY046960225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY046960OtherLICENSE