Provider Demographics
NPI:1992376990
Name:GLADSTONE, KAYLA YVONNE
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:YVONNE
Last Name:GLADSTONE
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 1:15 CANNONGATE RD APT 47
Mailing Address - Street 2:
Mailing Address - City:TYNGSBORO
Mailing Address - State:MA
Mailing Address - Zip Code:01879-1425
Mailing Address - Country:US
Mailing Address - Phone:251-623-4183
Mailing Address - Fax:
Practice Address - Street 1:505 W HOLLIS ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03062-1358
Practice Address - Country:US
Practice Address - Phone:603-595-7434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225700000X
NH8026225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty