Provider Demographics
NPI:1437142379
Name:BELL, KAYLA SHAYE (PA)
Entity Type:Individual
Prefix:MRS
First Name:KAYLA
Middle Name:SHAYE
Last Name:BELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:KAYLA
Other - Middle Name:SHAYE
Other - Last Name:FUNKHOUSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:213 NW 11TH STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837
Mailing Address - Country:US
Mailing Address - Phone:618-842-4617
Mailing Address - Fax:618-842-4743
Practice Address - Street 1:213 NW 11TH STREET
Practice Address - Street 2:SUITE A
Practice Address - City:FAIRFIELD
Practice Address - State:IL
Practice Address - Zip Code:62837
Practice Address - Country:US
Practice Address - Phone:618-842-4617
Practice Address - Fax:618-842-4743
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL85002406363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL1682017Medicare PIN
ILQ71260Medicare UPIN
ILK30036Medicare PIN
ILK30037Medicare PIN