Provider Demographics
NPI:1619521846
Name:EBBEN, KAYLA ANN (RN)
Entity Type:Individual
Prefix:MRS
First Name:KAYLA
Middle Name:ANN
Last Name:EBBEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:KAYLA
Other - Middle Name:ANN
Other - Last Name:VANDERMUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1314 COOLIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:LITTLE CHUTE
Mailing Address - State:WI
Mailing Address - Zip Code:54140-2340
Mailing Address - Country:US
Mailing Address - Phone:920-536-0831
Mailing Address - Fax:
Practice Address - Street 1:N4673 MAYFLOWER RD
Practice Address - Street 2:
Practice Address - City:BLACK CREEK
Practice Address - State:WI
Practice Address - Zip Code:54106-8025
Practice Address - Country:US
Practice Address - Phone:920-757-5716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-25
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI241330163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse