Healthcare Provider Details

I. General information

NPI: 1407014723
Provider Name (Legal Business Name): KYLIE MICHELLE HUTSELL P A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2008
Last Update Date: 05/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11912 ELM ST STE 26
OMAHA NE
68144-4363
US

IV. Provider business mailing address

11912 ELM ST STE 26
OMAHA NE
68144-4363
US

V. Phone/Fax

Practice location:
  • Phone: 402-330-4770
  • Fax: 402-330-2711
Mailing address:
  • Phone: 402-330-4770
  • Fax: 402-330-2711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2291
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: