Provider Demographics
NPI:1285492173
Name:BOURGAULT, KAYLA ANN
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:ANN
Last Name:BOURGAULT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAYL
Other - Middle Name:A
Other - Last Name:BOURGAULT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2957 FLORAL HILL DR
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97403-2279
Mailing Address - Country:US
Mailing Address - Phone:831-428-5080
Mailing Address - Fax:
Practice Address - Street 1:150 SHELTON MCMURPHEY BLVD STE 101
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-5015
Practice Address - Country:US
Practice Address - Phone:541-210-8090
Practice Address - Fax:541-210-5310
Is Sole Proprietor?:No
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist