Provider Demographics
NPI:1053946343
Name:WALLETTE, KAYLA M (AAS)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:M
Last Name:WALLETTE
Suffix:
Gender:F
Credentials:AAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HIGHWAY 2 W
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-3532
Mailing Address - Country:US
Mailing Address - Phone:701-665-2200
Mailing Address - Fax:701-665-2300
Practice Address - Street 1:1102 MAIN AVE
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:ND
Practice Address - Zip Code:58367
Practice Address - Country:US
Practice Address - Phone:701-477-9050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other