Provider Demographics
NPI:1437817897
Name:DOUGLES, KAITLIN (NP)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:DOUGLES
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 1:26901 76TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1433
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26901 76TH AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1433
Practice Address - Country:US
Practice Address - Phone:650-497-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-02
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95019228208000000X, 363L00000X
NY383450363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner