Provider Demographics
NPI:1083957716
Name:KYLE, BETTY WANDA
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:WANDA
Last Name:KYLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 CHRISTIAN CIR SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-5823
Mailing Address - Country:US
Mailing Address - Phone:770-679-6245
Mailing Address - Fax:770-602-1723
Practice Address - Street 1:1180 CHRISTIAN CIR SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-5823
Practice Address - Country:US
Practice Address - Phone:770-679-6245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-01
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACNA CERTIFICATION376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide