Provider Demographics
NPI:1356010839
Name:KING, KAITLIN NICHOLE
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:NICHOLE
Last Name:KING
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 1:1601 N PARK DR
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AZ
Mailing Address - Zip Code:86047-2559
Mailing Address - Country:US
Mailing Address - Phone:928-289-4615
Mailing Address - Fax:
Practice Address - Street 1:4055 S DURANGO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-4158
Practice Address - Country:US
Practice Address - Phone:702-869-9503
Practice Address - Fax:702-869-4328
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS025405183500000X
NV23057183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist