Basic Information
| Provider Information | |||||||||
| NPI: | 1346868296 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBBONS | ||||||||
| FirstName: | KAYLA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 106 S HOLMEN DR STE 2 | ||||||||
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| City: | HOLMEN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546369468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6085269888 | ||||||||
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| Practice Location | |||||||||
| Address1: | 198 COUNTY ROAD DF | ||||||||
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| City: | JUNEAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530399515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203863548 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2020 | ||||||||
| LastUpdateDate: | 07/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2483-19 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.