Provider Demographics
NPI:1063226447
Name:MARTY, KAYLA (RN)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:MARTY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:
Other - Last Name:MAYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3712 CRYSTAL SPRING DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-7161
Mailing Address - Country:US
Mailing Address - Phone:217-725-3817
Mailing Address - Fax:
Practice Address - Street 1:3712 CRYSTAL SPRING DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-7161
Practice Address - Country:US
Practice Address - Phone:217-725-3817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041393198163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse