Healthcare Provider Details

I. General information

NPI: 1962129007
Provider Name (Legal Business Name): KYLA BOSWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2022
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 INTREPID AVE
PHILADELPHIA PA
19112-1229
US

IV. Provider business mailing address

2801 S GRAND BLVD APT 4
SPOKANE WA
99203-2562
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberRN61274038
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: