Provider Demographics
NPI:1770018269
Name:BACKING, KAITLYN HALEY (PA)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:HALEY
Last Name:BACKING
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:
Other - Last Name:KIMMEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1170 FOX CT
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-5968
Mailing Address - Country:US
Mailing Address - Phone:248-881-3483
Mailing Address - Fax:
Practice Address - Street 1:845 S LAPEER RD
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362-2925
Practice Address - Country:US
Practice Address - Phone:248-469-0011
Practice Address - Fax:248-621-4327
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-22
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008071363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical