Basic Information
| Provider Information | |||||||||
| NPI: | 1881142677 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERRERA | ||||||||
| FirstName: | KAYLA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SENDELBACH | ||||||||
| OtherFirstName: | KAYLA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 329 N WEST ST | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458014332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192213072 | ||||||||
| FaxNumber: | 4195495671 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 SPARTAN WAY | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199963436 | ||||||||
| FaxNumber: | 4192258878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2016 | ||||||||
| LastUpdateDate: | 05/30/2018 | ||||||||
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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 | 363A00000X | 50.004690RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0186464 | 05 | OH | MEDICAID |