Provider Demographics
NPI:1164526612
Name:PRINCE, KAYLE M (NP)
Entity Type:Individual
Prefix:
First Name:KAYLE
Middle Name:M
Last Name:PRINCE
Suffix:
Gender:F
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:UNIT 2310 BOX 47
Mailing Address - Street 2:
Mailing Address - City:DPO
Mailing Address - State:AE
Mailing Address - Zip Code:09816-0047
Mailing Address - Country:US
Mailing Address - Phone:26021-135-7000
Mailing Address - Fax:
Practice Address - Street 1:UNIT 2310 BOX 47
Practice Address - Street 2:
Practice Address - City:DPO
Practice Address - State:AE
Practice Address - Zip Code:09816-0047
Practice Address - Country:US
Practice Address - Phone:21126-035-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT33178363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4309466Medicaid
MT370831OtherBCBS
MT4309461Medicaid
MT370831OtherBCBS
S65923Medicare UPIN
MT000071959Medicare PIN
MT4309466Medicaid