Provider Demographics
NPI:1841813391
Name:UTLEY, KAILEY
Entity type:Individual
Prefix:
First Name:KAILEY
Middle Name:
Last Name:UTLEY
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 1:11362 BURGESS AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-3102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8010 OAK PARK RD NE
Practice Address - Street 2:
Practice Address - City:NEW SALISBURY
Practice Address - State:IN
Practice Address - Zip Code:47161-8401
Practice Address - Country:US
Practice Address - Phone:812-366-3147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020015887152W00000X
IN18004367A152W00000X
KY2374DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist