=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114525284
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. KYLA WARNICK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2020
-----------------------------------------------------
Last Update Date | 06/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1310 W B ST
-----------------------------------------------------
City | RUSSELLVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72801-2802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-857-5036
-----------------------------------------------------
Fax | 479-974-2010
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1705 SKYLINE DR
-----------------------------------------------------
City | RUSSELLVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72802-9072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-857-5036
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 202100
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------