Healthcare Provider Details

I. General information

NPI: 1386560068
Provider Name (Legal Business Name): KAITLIN KAYE ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 12TH STREET EXT
PRINCETON WV
24740-2329
US

IV. Provider business mailing address

167 SPLITRAIL LN
ROCK WV
24747-6100
US

V. Phone/Fax

Practice location:
  • Phone: 304-425-9541
  • Fax:
Mailing address:
  • Phone: 681-323-8646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: