Healthcare Provider Details

I. General information

NPI: 1457187528
Provider Name (Legal Business Name): KYLE MITCHEL DISNEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2024
Last Update Date: 09/13/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WEST BOCA MEDICAL CENTER 21644 N STATE ROAD 7
BOCA RATON FL
33428
US

IV. Provider business mailing address

5374 NW 117TH AVE
CORAL SPRINGS FL
33076-3214
US

V. Phone/Fax

Practice location:
  • Phone: 561-488-8000
  • Fax:
Mailing address:
  • Phone: 305-205-8751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberAPRN11035101
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: