Provider Demographics
NPI:1285377192
Name:ELSASS, KAYCIE LYNN
Entity type:Individual
Prefix:MS
First Name:KAYCIE
Middle Name:LYNN
Last Name:ELSASS
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 1:35325 DATE PALM DR STE 153F
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-7086
Mailing Address - Country:US
Mailing Address - Phone:760-537-1258
Mailing Address - Fax:
Practice Address - Street 1:35325 DATE PALM DR STE 153F
Practice Address - Street 2:
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-7086
Practice Address - Country:US
Practice Address - Phone:937-507-5816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL9698247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZ126827OtherDEPARTMENT OF CONSUMER AFFAIRS/ ESTHETICIAN
CAL9698OtherDEPARTMENT OF CONSUMER AFFAIRS/ ELECTROLOGIST