MEDICARE: MR. KYLE JOSEPH HENRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	95025257	CA

General Provider Information

NPI Number	:	1932891124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KYLE JOSEPH HENRY

Provider Business Mailing Address
First Line	:	5820 WOODMAN AVE
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91401-4429
Country	:	US
Telephone Number	:	661-478-7151
Fax Number	:

Provider Business Practice Location Address
First Line	:	19042 SOLEDAD CANYON RD
Second Line	:
City	:	SANTA CLARITA
State	:	CA
Zip	:	91351-3362
Country	:	US
Telephone Number	:	661-251-6300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2023
Last Update Date	:	05/24/2023

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