Provider Demographics
NPI:1184261356
Name:PAGE, KAYLA
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:PAGE
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 1:10061 RIVER BLUFF LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-4127
Mailing Address - Country:US
Mailing Address - Phone:209-518-6180
Mailing Address - Fax:
Practice Address - Street 1:571 BELLEVUE RD
Practice Address - Street 2:
Practice Address - City:ATWATER
Practice Address - State:CA
Practice Address - Zip Code:95301-2928
Practice Address - Country:US
Practice Address - Phone:209-358-6306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-05
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81357183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist