Provider Demographics
NPI:1285176636
Name:MAMMEN, KAYLA MARIE (PT, DPT)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:MARIE
Last Name:MAMMEN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2302 SCARBOROUGH DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68123-2082
Mailing Address - Country:US
Mailing Address - Phone:402-821-7308
Mailing Address - Fax:
Practice Address - Street 1:1276 SAND HILL RD
Practice Address - Street 2:#2
Practice Address - City:LOUISVILLE
Practice Address - State:NE
Practice Address - Zip Code:68037
Practice Address - Country:US
Practice Address - Phone:402-234-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-15
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0014429225100000X
NE0014429225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1285176636OtherINDIVIDUAL NPI