Healthcare Provider Details

I. General information

NPI: 1225067325
Provider Name (Legal Business Name): KYLE WINDSOR DEBENHAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KYLE WINDSOR TILDER MD

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 MAPLE AVE W
VIENNA VA
22180-5727
US

IV. Provider business mailing address

PO BOX 37174
BALTIMORE MD
21297-3174
US

V. Phone/Fax

Practice location:
  • Phone: 703-938-5300
  • Fax: 703-242-0726
Mailing address:
  • Phone: 571-423-5699
  • Fax: 571-423-5698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5578A
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number41491
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101266146
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: