Provider Demographics
NPI:1245772953
Name:VINCENT, KYLIE
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:VINCENT
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 1:3937 YOSEMITE AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2821
Mailing Address - Country:US
Mailing Address - Phone:612-275-9155
Mailing Address - Fax:
Practice Address - Street 1:3937 YOSEMITE AVE S
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2821
Practice Address - Country:US
Practice Address - Phone:612-275-9155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-11
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN204856-5163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse