Provider Demographics
NPI:1336692870
Name:PAVAO, KAYLA (NP)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:PAVAO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1342 BELMONT ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-4436
Mailing Address - Country:US
Mailing Address - Phone:508-973-7041
Mailing Address - Fax:
Practice Address - Street 1:1342 BELMONT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4436
Practice Address - Country:US
Practice Address - Phone:508-973-7041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN01989363L00000X
MARN2286207363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MARN2286207OtherCERTIFIED NURSE PRACTITIONER
MAMR1050296NOtherMASS CONTROLLED SUBSTANCE REGISTRATION