Provider Demographics
NPI:1205330610
Name:ST AMOUR, KAYLA
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:ST AMOUR
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 1:35 TIFT ST
Mailing Address - Street 2:
Mailing Address - City:JEWETT CITY
Mailing Address - State:CT
Mailing Address - Zip Code:06351-1821
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:86 NEW LONDON TPKE
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2616
Practice Address - Country:US
Practice Address - Phone:860-889-6967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7510363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology