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General NPI Number Information
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NPI Number | 1588480685
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Entity Type | Individual
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Provider Name | KYLE RYAN FARIS ACNPC-AG
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Gender | Male
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Dates
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Enumeration Date | 11/23/2024
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Last Update Date | 07/12/2025
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Provider Practice Location Address
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Address Line | 1001 MAIN ST STE 200
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City | PEORIA
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State | IL
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Zip | 61606-2035
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Country | US
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Telephone | 309-672-5682
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Fax | 309-672-3147
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Provider Business Mailing Address
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Address Line | 10210 NE 189TH ST UNIT A
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City | BOTHELL
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State | WA
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Zip | 98011-3836
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Country | US
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Telephone | 760-217-8584
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 209032698
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License Number State | IL
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