Provider Demographics
NPI:1114271210
Name:WILSON, KYLE J
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:J
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 N BAGLEY ST
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-8215
Mailing Address - Country:US
Mailing Address - Phone:989-354-4484
Mailing Address - Fax:989-354-4474
Practice Address - Street 1:1033 N BAGLEY ST
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-8215
Practice Address - Country:US
Practice Address - Phone:989-354-4484
Practice Address - Fax:989-354-4474
Is Sole Proprietor?:No
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI35010005495237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist