Basic Information
| Provider Information | |||||||||
| NPI: | 1821712068 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LANGE | ||||||||
| FirstName: | KAITLIN | ||||||||
| MiddleName: | RAELEEN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6845 CASTLEROCK TRL APT C | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454596024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372397818 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 405 B WASHINGTON JACKSON ROAD | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | EATON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374568330 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2022 | ||||||||
| LastUpdateDate: | 09/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 50.007778RX | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.