Healthcare Provider Details

I. General information

NPI: 1891511432
Provider Name (Legal Business Name): KYSEN DANE SUE CPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2024
Last Update Date: 11/27/2024
Certification Date: 11/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4617 50TH ST STE 5
LUBBOCK TX
79414-3507
US

IV. Provider business mailing address

5815 82ND ST, SUITE 145 / PMB 108
LUBBOCK TX
79424
US

V. Phone/Fax

Practice location:
  • Phone: 806-599-6299
  • Fax:
Mailing address:
  • Phone: 806-599-6299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License NumberNPCN-17321-11162
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: