Healthcare Provider Details

I. General information

NPI: 1952996548
Provider Name (Legal Business Name): KYLE OMAR WASHINGTON FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2021
Last Update Date: 07/17/2022
Certification Date: 07/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 VANDENBURGH AVE
TROY NY
12180-6024
US

IV. Provider business mailing address

PO BOX 14890
ALBANY NY
12212-4890
US

V. Phone/Fax

Practice location:
  • Phone: 518-271-0063
  • Fax:
Mailing address:
  • Phone: 518-525-5636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number345661
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: