Provider Demographics
NPI:1033737770
Name:WHITE, KYLE LYNDON (DPT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:LYNDON
Last Name:WHITE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PONTOTOC
Mailing Address - State:MS
Mailing Address - Zip Code:38863-3305
Mailing Address - Country:US
Mailing Address - Phone:662-419-1979
Mailing Address - Fax:
Practice Address - Street 1:111 HIGHWAY 15 S
Practice Address - Street 2:
Practice Address - City:PONTOTOC
Practice Address - State:MS
Practice Address - Zip Code:38863-2628
Practice Address - Country:US
Practice Address - Phone:662-586-2444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT6900390200000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program