Provider Demographics
NPI:1306539440
Name:BLACK, KYLEE
Entity type:Individual
Prefix:
First Name:KYLEE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KYLEE
Other - Middle Name:
Other - Last Name:ALTENDORF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4957 13K ST NW
Mailing Address - Street 2:
Mailing Address - City:GARRISON
Mailing Address - State:ND
Mailing Address - Zip Code:58540-9629
Mailing Address - Country:US
Mailing Address - Phone:701-720-9348
Mailing Address - Fax:
Practice Address - Street 1:9800 S HEALTHPARK DR STE 110
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3630
Practice Address - Country:US
Practice Address - Phone:239-343-6202
Practice Address - Fax:239-343-4159
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-02
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9117571363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL118592000Medicaid