Provider Demographics
NPI:1952152035
Name:BLACKSTAD, KAYLYNN RAE (MD)
Entity type:Individual
Prefix:
First Name:KAYLYNN
Middle Name:RAE
Last Name:BLACKSTAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KAYLYNN
Other - Middle Name:RAE
Other - Last Name:WILKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:245 FOUNTAIN CT STE 225
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-2794
Mailing Address - Country:US
Mailing Address - Phone:859-323-6861
Mailing Address - Fax:
Practice Address - Street 1:245 FOUNTAIN CT STE 225
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2794
Practice Address - Country:US
Practice Address - Phone:859-323-6861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program