MEDICARE: MR. KYLE EDWIN JERSEY R.N.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WM1400X	Nurse Massage Therapist (NMT)	RN9264326	FL
2	225700000X	Massage Therapist	MA60871	FL

General Provider Information

NPI Number	:	1760774939
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KYLE EDWIN JERSEY R.N.

Provider Business Mailing Address
First Line	:	1128 NE 20TH PLACE
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32609
Country	:	US
Telephone Number	:	352-234-6677
Fax Number	:

Provider Business Practice Location Address
First Line	:	1128 NE 20TH PLACE
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32609
Country	:	US
Telephone Number	:	352-234-6677
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/06/2011
Last Update Date	:	05/06/2011

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