=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629867973
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLE F ROTONDO FNP-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2025
-----------------------------------------------------
Last Update Date | 09/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1951 OAK ST
-----------------------------------------------------
City | NILES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49120-3738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-262-4749
-----------------------------------------------------
Fax | 269-262-4739
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 MOCCASIN ST
-----------------------------------------------------
City | BUCHANAN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49107-1218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-813-6643
-----------------------------------------------------
Fax | 312-813-6643
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | 4704401501
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WE0003X
-----------------------------------------------------
Taxonomy Name | Emergency Registered Nurse
-----------------------------------------------------
License Number | 4704401501
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------