Healthcare Provider Details

I. General information

NPI: 1821420126
Provider Name (Legal Business Name): KYLE LACY HODGES APRN-FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2013
Last Update Date: 04/03/2020
Certification Date: 04/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 MAPLE AVE
OAKLEY KS
67748-1220
US

IV. Provider business mailing address

212 MAPLE AVE
OAKLEY KS
67748-1220
US

V. Phone/Fax

Practice location:
  • Phone: 785-672-3261
  • Fax: 785-672-8194
Mailing address:
  • Phone: 785-672-3261
  • Fax: 785-672-8194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number147228
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number147228
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: