Provider Demographics
NPI:1699556811
Name:DECKER, KYLEIGH SUE (PA-C)
Entity type:Individual
Prefix:
First Name:KYLEIGH
Middle Name:SUE
Last Name:DECKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 NORTHVIEW ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-8911
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5049
Practice Address - Country:US
Practice Address - Phone:573-331-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023040432207P00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine