Basic Information
| Provider Information | |||||||||
| NPI: | 1811246275 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROSS | ||||||||
| FirstName: | KAYLA | ||||||||
| MiddleName: | ELISE CAPIZZANO | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40 | ||||||||
| Address2: | |||||||||
| City: | SOUTHBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015500040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089097799 | ||||||||
| FaxNumber: | 5087642432 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 E OLD STURBRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | BRIMFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010109647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4132450966 | ||||||||
| FaxNumber: | 4132454553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2012 | ||||||||
| LastUpdateDate: | 08/18/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 005049 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 2270500 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0053436 | 01 | CT | CSP | OTHER | 12.005049 | 01 | CT | APRN | OTHER |