Provider Demographics
NPI:1447886171
Name:MATTIELLO, KAYLEE J (PA-C)
Entity type:Individual
Prefix:
First Name:KAYLEE
Middle Name:J
Last Name:MATTIELLO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAYLEE
Other - Middle Name:J
Other - Last Name:TAILLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:455 TOLL GATE RD
Mailing Address - Street 2:PRC AND CREDENTIALING
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886
Mailing Address - Country:US
Mailing Address - Phone:401-273-0641
Mailing Address - Fax:401-273-2919
Practice Address - Street 1:1407 S COUNTY TRL STE 430A
Practice Address - Street 2:
Practice Address - City:EAST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818-1679
Practice Address - Country:US
Practice Address - Phone:401-886-7910
Practice Address - Fax:401-886-7913
Is Sole Proprietor?:No
Enumeration Date:2020-03-13
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA01217363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant