Provider Demographics
NPI:1790195535
Name:EGGEN, KAYLA (COTA)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:EGGEN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1270 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:WI
Mailing Address - Zip Code:54002-6301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1119 OWENS ST N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-4316
Practice Address - Country:US
Practice Address - Phone:651-439-7180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-01
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN201928224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant