Provider Demographics
NPI:1407329428
Name:HICKMANN, KAYLA M (CAA)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:M
Last Name:HICKMANN
Suffix:
Gender:F
Credentials:CAA
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:
Other - Last Name:OETTING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CAA
Mailing Address - Street 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-4920
Mailing Address - Fax:
Practice Address - Street 1:430 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4560
Practice Address - Country:US
Practice Address - Phone:920-926-4920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-03
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI121367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant