Provider Demographics
NPI:1174071625
Name:LODGE, KAYLA (PA-C)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:LODGE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:325 PRINCETON AVE
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-1698
Mailing Address - Country:US
Mailing Address - Phone:609-924-8131
Mailing Address - Fax:609-924-8532
Practice Address - Street 1:325 PRINCETON AVE
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-1698
Practice Address - Country:US
Practice Address - Phone:609-924-8131
Practice Address - Fax:609-924-8532
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00409800363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant