Provider Demographics
NPI:1841956984
Name:GILLETTE, KALEIGH
Entity type:Individual
Prefix:
First Name:KALEIGH
Middle Name:
Last Name:GILLETTE
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 1:2951 KNOLLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CAMERON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:95682-9046
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 CREEKSIDE DR
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3400
Practice Address - Country:US
Practice Address - Phone:916-983-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-12
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60715363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program