Provider Demographics
NPI:1770811903
Name:LICARI, KAYLA R (PA-C)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:R
Last Name:LICARI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:R
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:P-A-C
Mailing Address - Street 1:3700 52ND ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-9637
Mailing Address - Country:US
Mailing Address - Phone:616-656-3700
Mailing Address - Fax:616-656-3701
Practice Address - Street 1:3700 52ND ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-9637
Practice Address - Country:US
Practice Address - Phone:616-656-3700
Practice Address - Fax:616-656-3701
Is Sole Proprietor?:No
Enumeration Date:2009-11-30
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005659363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601005659OtherSTATE LICENSE