Provider Demographics
NPI:1114671534
Name:BLEVINS, KYLE TRAVIS (LPN)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:TRAVIS
Last Name:BLEVINS
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6721 REGENTS BLVD
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-5461
Mailing Address - Country:US
Mailing Address - Phone:253-433-7755
Mailing Address - Fax:
Practice Address - Street 1:6721 REGENTS BLVD
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-5461
Practice Address - Country:US
Practice Address - Phone:253-433-7755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-04
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP61138348164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse