Healthcare Provider Details

I. General information

NPI: 1669025169
Provider Name (Legal Business Name): KYLE BENJAMIN STINSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8305 SE MONTEREY AVE
HAPPY VALLEY OR
97086-7725
US

IV. Provider business mailing address

PO BOX 8459
PORTLAND OR
97207-8459
US

V. Phone/Fax

Practice location:
  • Phone: 971-278-4594
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: