Healthcare Provider Details

I. General information

NPI: 1891807947
Provider Name (Legal Business Name): KYLE CLIFFTON DENNIS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 06/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2910 JENNY LIND RD
FORT SMITH AR
72901-6735
US

IV. Provider business mailing address

PO BOX 11286
FORT SMITH AR
72917-1286
US

V. Phone/Fax

Practice location:
  • Phone: 479-785-2555
  • Fax: 479-785-3555
Mailing address:
  • Phone: 479-785-2555
  • Fax: 479-785-3555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC01542
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: