Healthcare Provider Details

I. General information

NPI: 1275912636
Provider Name (Legal Business Name): KYLE WILLARD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2015
Last Update Date: 05/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E MICHIGAN AVE
LANSING MI
48912-1811
US

IV. Provider business mailing address

2375 CLUB MERIDIAN DR APT B-12
OKEMOS MI
48864-4520
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-1000
  • Fax:
Mailing address:
  • Phone: 810-887-1598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704278897
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: