Provider Demographics
NPI:1629449483
Name:SHATTUCK, KAYLA LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:LYNN
Last Name:SHATTUCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:LYNN
Other - Last Name:MIZGALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:100 OMNI DR STE B
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672-9448
Practice Address - Country:US
Practice Address - Phone:864-886-9250
Practice Address - Fax:864-886-9251
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4398363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant