Basic Information
| Provider Information | |||||||||
| NPI: | 1336104934 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LADD | ||||||||
| FirstName: | KYLEE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3832 GRASSMERE RD | ||||||||
| Address2: | |||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605648234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083266270 | ||||||||
| FaxNumber: | 7089955417 | ||||||||
| Practice Location | |||||||||
| Address1: | 260 CREST RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SAINT ALBANS | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054789503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8025241223 | ||||||||
| FaxNumber: | 8025241095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 05/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 055-0030279 | VT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 9000230 | 05 | VT | MEDICAID |