Provider Demographics
NPI:1235751785
Name:GARY, CAITLYN MICHELLE
Entity Type:Individual
Prefix:
First Name:CAITLYN
Middle Name:MICHELLE
Last Name:GARY
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 1:3741 LOGANSPORT RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42261-8055
Mailing Address - Country:US
Mailing Address - Phone:270-532-0211
Mailing Address - Fax:
Practice Address - Street 1:201 S WARREN ST
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:KY
Practice Address - Zip Code:42261-9416
Practice Address - Country:US
Practice Address - Phone:270-526-3368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-07
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1156950163W00000X
KY3016249363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1156950OtherKENTUCKY BOARD OF NURSING