Provider Demographics
NPI:1285276998
Name:CHURCHILL, KAYLA MARIE
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:MARIE
Last Name:CHURCHILL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 N LEONA ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-4232
Mailing Address - Country:US
Mailing Address - Phone:920-730-1028
Mailing Address - Fax:920-730-9219
Practice Address - Street 1:1308 N LEONA ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-4232
Practice Address - Country:US
Practice Address - Phone:920-730-1028
Practice Address - Fax:920-730-9219
Is Sole Proprietor?:No
Enumeration Date:2019-10-14
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator