Provider Demographics
NPI:1306663422
Name:DEMO, KAELLA RAE (RN)
Entity type:Individual
Prefix:MRS
First Name:KAELLA
Middle Name:RAE
Last Name:DEMO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 CRESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-9678
Mailing Address - Country:US
Mailing Address - Phone:307-275-5476
Mailing Address - Fax:
Practice Address - Street 1:2360 E PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5356
Practice Address - Country:US
Practice Address - Phone:307-778-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY32217163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse