=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346825189
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLELYNE DEEANNE THAYER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2021
-----------------------------------------------------
Last Update Date | 03/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4542 KENOWA AVE SW
-----------------------------------------------------
City | GRANDVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49418-9523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-667-9713
-----------------------------------------------------
Fax | 616-667-9715
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3865 YORKLAND DR NW APT 7
-----------------------------------------------------
City | COMSTOCK PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49321-8138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-490-8961
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183700000X
-----------------------------------------------------
Taxonomy Name | Pharmacy Technician
-----------------------------------------------------
License Number | 5303014544
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------