Healthcare Provider Details

I. General information

NPI: 1780496133
Provider Name (Legal Business Name): KAITLYN VANCE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2025
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 E HOFFER ST
KOKOMO IN
46902-2474
US

IV. Provider business mailing address

1315 E HOFFER ST
KOKOMO IN
46902-2474
US

V. Phone/Fax

Practice location:
  • Phone: 765-419-0411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-80637
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-160167
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: