Provider Demographics
NPI:1053629857
Name:MCCLINTOCK, KYLE THERESA (CRNA)
Entity Type:Individual
Prefix:MS
First Name:KYLE
Middle Name:THERESA
Last Name:MCCLINTOCK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 MARY LN
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND FORESIDE
Mailing Address - State:ME
Mailing Address - Zip Code:04110-1442
Mailing Address - Country:US
Mailing Address - Phone:860-280-5125
Mailing Address - Fax:
Practice Address - Street 1:175 FORE RIVER PKWY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2779
Practice Address - Country:US
Practice Address - Phone:207-879-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERN83171163W00000X
CT075000163W00000X, 367500000X
CT004584367500000X
MERNA223051367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse