Healthcare Provider Details

I. General information

NPI: 1831672559
Provider Name (Legal Business Name): KAITLIN ALYSSA GIDDENS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2018
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1049 N HOUSTON RD
WARNER ROBINS GA
31093-1505
US

IV. Provider business mailing address

472 ORANGE ST
MACON GA
31201-6734
US

V. Phone/Fax

Practice location:
  • Phone: 478-231-5977
  • Fax:
Mailing address:
  • Phone: 478-231-5977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11514
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: