Provider Demographics
NPI:1932816808
Name:FEARON, KAYLA HAGAN (PTA)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:HAGAN
Last Name:FEARON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 COMPASS RD
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-8001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:815 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:IN
Practice Address - Zip Code:47635-1252
Practice Address - Country:US
Practice Address - Phone:812-649-2276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06006432A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant