Provider Demographics
NPI:1831749852
Name:INNISS, KAITLIN
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:INNISS
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 1:2811 FOOTHILLS RD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4536
Mailing Address - Country:US
Mailing Address - Phone:307-421-6389
Mailing Address - Fax:
Practice Address - Street 1:17017 N 12TH ST UNIT 1003
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-2031
Practice Address - Country:US
Practice Address - Phone:307-421-6389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-12
Last Update Date:2022-03-26
Deactivation Date:2021-08-18
Deactivation Code:
Reactivation Date:2021-10-14
Provider Licenses
StateLicense IDTaxonomies
AZ390200000X
AZATR-0093022255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty