Provider Demographics
NPI:1295598522
Name:FETZKO, KAILEY DEVINE (DC)
Entity type:Individual
Prefix:DR
First Name:KAILEY
Middle Name:DEVINE
Last Name:FETZKO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:891 MENOHER BLVD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-2839
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:891 MENOHER BLVD
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-2839
Practice Address - Country:US
Practice Address - Phone:814-418-8017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC011901111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor