Healthcare Provider Details

I. General information

NPI: 1033955786
Provider Name (Legal Business Name): KYLIE NOELLE STEPHENS P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2024
Last Update Date: 08/08/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 DAVIS AVE FL 4
NEPTUNE CITY NJ
07753-4488
US

IV. Provider business mailing address

331 NEWMAN SPRINGS RD STE 220
RED BANK NJ
07701-5792
US

V. Phone/Fax

Practice location:
  • Phone: 732-974-0003
  • Fax:
Mailing address:
  • Phone: 732-807-0877
  • Fax: 201-751-1680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP00862200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: