=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033955786
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLIE NOELLE STEPHENS P.A.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2024
-----------------------------------------------------
Last Update Date | 08/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19 DAVIS AVE FL 4
-----------------------------------------------------
City | NEPTUNE CITY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07753-4488
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-974-0003
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 331 NEWMAN SPRINGS RD STE 220
-----------------------------------------------------
City | RED BANK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07701-5792
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-807-0877
-----------------------------------------------------
Fax | 201-751-1680
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 25MP00862200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------