Provider Demographics
NPI:1104579580
Name:CACCAMO, KAY LYN (RRT)
Entity type:Individual
Prefix:
First Name:KAY
Middle Name:LYN
Last Name:CACCAMO
Suffix:
Gender:F
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11906 S ANTHONY EXT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46819-9508
Mailing Address - Country:US
Mailing Address - Phone:260-639-6338
Mailing Address - Fax:
Practice Address - Street 1:11906 S ANTHONY EXT
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46819-9508
Practice Address - Country:US
Practice Address - Phone:260-639-6338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN30003676A227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredGroup - Single Specialty