Healthcare Provider Details

I. General information

NPI: 1235681636
Provider Name (Legal Business Name): KAYLA RICHARDSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KAYLA MULLEN PA-C

II. Dates (important events)

Enumeration Date: 11/01/2016
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 MIAMISBURG CENTERVILLE RD
CENTERVILLE OH
45459-3811
US

IV. Provider business mailing address

1975 MIAMISBURG CENTERVILLE RD
CENTERVILLE OH
45459-3811
US

V. Phone/Fax

Practice location:
  • Phone: 937-439-6186
  • Fax:
Mailing address:
  • Phone: 937-439-6186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.008048RX
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: