Healthcare Provider Details

I. General information

NPI: 1568326171
Provider Name (Legal Business Name): KYLA NAYSHELLE CHURCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 BLUE POINT AVE
BLUE POINT NY
11715-1224
US

IV. Provider business mailing address

263 BLUE POINT AVE
BLUE POINT NY
11715-1224
US

V. Phone/Fax

Practice location:
  • Phone: 631-419-6737
  • Fax:
Mailing address:
  • Phone: 631-419-6737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number353194-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: