Provider Demographics
NPI:1720591332
Name:WIECHELT, KAYLEE
Entity Type:Individual
Prefix:
First Name:KAYLEE
Middle Name:
Last Name:WIECHELT
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 1:2609 THREE ROD RD
Mailing Address - Street 2:
Mailing Address - City:EAST AURORA
Mailing Address - State:NY
Mailing Address - Zip Code:14052-9571
Mailing Address - Country:US
Mailing Address - Phone:716-864-2556
Mailing Address - Fax:
Practice Address - Street 1:2609 THREE ROD RD
Practice Address - Street 2:
Practice Address - City:EAST AURORA
Practice Address - State:NY
Practice Address - Zip Code:14052-9571
Practice Address - Country:US
Practice Address - Phone:716-864-2556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021617-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant