Basic Information
| Provider Information | |||||||||
| NPI: | 1932816808 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FEARON | ||||||||
| FirstName: | KAYLA | ||||||||
| MiddleName: | HAGAN | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 COMPASS RD | ||||||||
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| City: | GLENVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600268001 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 815 WASHINGTON ST | ||||||||
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| City: | ROCKPORT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 476351252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8126492276 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2022 | ||||||||
| LastUpdateDate: | 11/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 06006432A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.