Provider Demographics
NPI:1467804815
Name:HEFFERNON, KAITLYN ANNE
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ANNE
Last Name:HEFFERNON
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 1:5114 AMINDA ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66226-2682
Mailing Address - Country:US
Mailing Address - Phone:913-901-7658
Mailing Address - Fax:
Practice Address - Street 1:5114 AMINDA ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66226-2682
Practice Address - Country:US
Practice Address - Phone:913-901-7658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS390200000X
TX1362132225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program