Healthcare Provider Details

I. General information

NPI: 1326434556
Provider Name (Legal Business Name): KYLE LENEWEAVER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2015
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5151 N 9TH AVE # 305
PENSACOLA FL
32504-8721
US

IV. Provider business mailing address

1125 SANSOM ST APT 517
PHILADELPHIA PA
19107-4864
US

V. Phone/Fax

Practice location:
  • Phone: 850-416-6159
  • Fax:
Mailing address:
  • Phone: 727-224-2059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberUO3919
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberOS16687
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: