Healthcare Provider Details

I. General information

NPI: 1326670779
Provider Name (Legal Business Name): KYLIE KELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2020
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 VISTA BLVD
SPARKS NV
89436-6712
US

IV. Provider business mailing address

3150 VISTA BLVD
SPARKS NV
89436-6712
US

V. Phone/Fax

Practice location:
  • Phone: 775-409-4605
  • Fax:
Mailing address:
  • Phone: 775-409-4605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: