Healthcare Provider Details

I. General information

NPI: 1306684063
Provider Name (Legal Business Name): KYLEIGH GRACE ROBERTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2024
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 HUNTER CT
BOWLING GREEN KY
42103-7032
US

IV. Provider business mailing address

246 MOSS VIEW ST APT E
BOWLING GREEN KY
42101-5539
US

V. Phone/Fax

Practice location:
  • Phone: 270-904-5104
  • Fax:
Mailing address:
  • Phone: 615-598-8905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: