Provider Demographics
NPI:1306292230
Name:WOOLLEY, KAITLIN MICHELLE
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:MICHELLE
Last Name:WOOLLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAITLIN
Other - Middle Name:MICHELLE
Other - Last Name:KENNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:31400 JOHN R RD
Mailing Address - Street 2:APT 204
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-1900
Mailing Address - Country:US
Mailing Address - Phone:231-838-1055
Mailing Address - Fax:
Practice Address - Street 1:1400 N RITTER AVE STE 120
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3045
Practice Address - Country:US
Practice Address - Phone:317-355-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01086276A208600000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300052832Medicaid