Provider Demographics
NPI:1538672134
Name:HERWAT, KAITLYN FRANCIS (AT)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:FRANCIS
Last Name:HERWAT
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4029 FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-5435
Mailing Address - Country:US
Mailing Address - Phone:517-930-2508
Mailing Address - Fax:
Practice Address - Street 1:206 PAGE AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2418
Practice Address - Country:US
Practice Address - Phone:517-930-2508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010018152255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer