Healthcare Provider Details

I. General information

NPI: 1609523232
Provider Name (Legal Business Name): KAYLA CALDWELL RUSHER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2022
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 GANNETT DR
SOUTH PORTLAND ME
04106-6942
US

IV. Provider business mailing address

119 GANNETT DR
SOUTH PORTLAND ME
04106-6942
US

V. Phone/Fax

Practice location:
  • Phone: 207-773-0040
  • Fax: 207-661-4630
Mailing address:
  • Phone: 207-773-0040
  • Fax: 207-661-4630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2918
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA2918
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2023038561
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: