Provider Demographics
NPI:1881281723
Name:MCCLAIN, KYLIE ALLISSA (PA-C)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:ALLISSA
Last Name:MCCLAIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KYLIE
Other - Middle Name:ALISSA
Other - Last Name:HANNOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:123 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1409
Practice Address - Country:US
Practice Address - Phone:814-371-1900
Practice Address - Fax:814-503-8568
Is Sole Proprietor?:No
Enumeration Date:2020-12-27
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
PAMA062018363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103894366Medicaid