Provider Demographics
NPI:1275135113
Name:HEISEY, KAYLA N
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:N
Last Name:HEISEY
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 1:274 W NATIONAL RD APT 5
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377-1946
Mailing Address - Country:US
Mailing Address - Phone:937-203-6557
Mailing Address - Fax:
Practice Address - Street 1:274 W NATIONAL RD APT 5
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:OH
Practice Address - Zip Code:45377-1946
Practice Address - Country:US
Practice Address - Phone:937-203-6557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5505101Medicaid