Healthcare Provider Details

I. General information

NPI: 1083550628
Provider Name (Legal Business Name): KYLIE DENISE HARGRAVE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 S LIMESTONE ST 205 CHARLES T WETHINGTON
LEXINGTON KY
40536-0001
US

IV. Provider business mailing address

115 BLACKBERRY RDG
GEORGETOWN KY
40324-9648
US

V. Phone/Fax

Practice location:
  • Phone: 859-218-0567
  • Fax:
Mailing address:
  • Phone: 859-533-6334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: