Provider Demographics
NPI:1700168408
Name:FILLMORE, KAYLA
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:FILLMORE
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 1:475 STATE HIGHWAY 49
Mailing Address - Street 2:
Mailing Address - City:SUTTER CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:95685-4195
Mailing Address - Country:US
Mailing Address - Phone:209-267-5128
Mailing Address - Fax:209-267-9146
Practice Address - Street 1:475 STATE HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:SUTTER CREEK
Practice Address - State:CA
Practice Address - Zip Code:95685-4195
Practice Address - Country:US
Practice Address - Phone:209-267-5128
Practice Address - Fax:209-267-9146
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63442183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist