Provider Demographics
NPI:1053033563
Name:MONHOLLEN, KAITLYN (PA-C)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:MONHOLLEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 802843
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-2843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7001 ROGERS AVE STE 501
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4073
Practice Address - Country:US
Practice Address - Phone:479-573-3101
Practice Address - Fax:479-573-3102
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MO2023009002363A00000X
ARPA-1129363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220122041Medicaid