Provider Demographics
NPI:1265029730
Name:PETRY, KAYLA NOELE
Entity Type:Individual
Prefix:MRS
First Name:KAYLA
Middle Name:NOELE
Last Name:PETRY
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 1:2636 COUNTY ROAD 137
Mailing Address - Street 2:
Mailing Address - City:CARDINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43315-9530
Mailing Address - Country:US
Mailing Address - Phone:567-231-8255
Mailing Address - Fax:
Practice Address - Street 1:2636 COUNTY ROAD 137
Practice Address - Street 2:
Practice Address - City:CARDINGTON
Practice Address - State:OH
Practice Address - Zip Code:43315-9530
Practice Address - Country:US
Practice Address - Phone:567-231-8255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5901108Medicaid