Provider Demographics
NPI:1093239717
Name:GUTERBA, KYLE (NP)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:GUTERBA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9400 N LIMA RD
Mailing Address - Street 2:
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-3224
Mailing Address - Country:US
Mailing Address - Phone:330-507-3089
Mailing Address - Fax:
Practice Address - Street 1:104 JAVIT CT
Practice Address - Street 2:
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-2439
Practice Address - Country:US
Practice Address - Phone:330-797-4050
Practice Address - Fax:330-953-1758
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCNP.021111363LF0000X
OHAPRN.CNP.021111363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0243652Medicaid