Provider Demographics
NPI:1487191367
Name:VICINO, KAYLA ROSE-ELAINE (PNP)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:ROSE-ELAINE
Last Name:VICINO
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 PROSPECT ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860
Mailing Address - Country:US
Mailing Address - Phone:401-728-9208
Mailing Address - Fax:
Practice Address - Street 1:126 PROSPECT ST STE 202
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-4429
Practice Address - Country:US
Practice Address - Phone:401-728-9208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2306249363LP0200X, 163W00000X
RIAPRN01733363LP0200X
RIRN56441163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse