Provider Demographics
NPI:1831672559
Name:GIDDENS, KAITLIN ALYSSA
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:ALYSSA
Last Name:GIDDENS
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 1:472 ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-6734
Mailing Address - Country:US
Mailing Address - Phone:478-231-5977
Mailing Address - Fax:
Practice Address - Street 1:1049 N HOUSTON RD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-1505
Practice Address - Country:US
Practice Address - Phone:478-231-5977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-09
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 363A00000X
GA11514363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer