=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427784503
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLER GREENE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2022
-----------------------------------------------------
Last Update Date | 07/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 130 SHADY LANE DR STE D
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44857-2710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 567-743-7199
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1382 BENBRANDON CT
-----------------------------------------------------
City | ONTARIO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44906-3239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number | APS.003460
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------