Provider Demographics
NPI:1306209028
Name:MAESTAS, KYLA
Entity Type:Individual
Prefix:
First Name:KYLA
Middle Name:
Last Name:MAESTAS
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 1:2011 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-4454
Mailing Address - Country:US
Mailing Address - Phone:307-371-2331
Mailing Address - Fax:307-382-5551
Practice Address - Street 1:2011 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-4454
Practice Address - Country:US
Practice Address - Phone:307-371-2331
Practice Address - Fax:307-382-5551
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY130030000OtherMEDICAID 9 DIGIT NPI