Provider Demographics
NPI:1013668276
Name:GAGNON, KAYLEIGH
Entity Type:Individual
Prefix:
First Name:KAYLEIGH
Middle Name:
Last Name:GAGNON
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 1:1111 FULTON AVE # 1
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-1529
Mailing Address - Country:US
Mailing Address - Phone:616-842-5350
Mailing Address - Fax:
Practice Address - Street 1:1111 FULTON AVE # 1
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-1529
Practice Address - Country:US
Practice Address - Phone:616-842-5350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator