=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487234613
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLE ROBERT HAINES LPN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2021
-----------------------------------------------------
Last Update Date | 04/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10196 STOREY GROVE WAY
-----------------------------------------------------
City | WINTER GARDEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34787-0086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-448-9675
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10196 STOREY GROVE WAY
-----------------------------------------------------
City | WINTER GARDEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34787-0086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-448-9675
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171400000X
-----------------------------------------------------
Taxonomy Name | Health & Wellness Coach
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174H00000X
-----------------------------------------------------
Taxonomy Name | Health Educator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | PN5239135
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------