Provider Demographics
NPI:1912791211
Name:KING, KAITLYN DAWN
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:DAWN
Last Name:KING
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 CLARKSON RD
Mailing Address - Street 2:
Mailing Address - City:VINE GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:40175-6098
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 DIECKS DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2443
Practice Address - Country:US
Practice Address - Phone:270-750-7848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-09
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty