Provider Demographics
NPI:1326826116
Name:ROBERTS, KYLEA RAYE
Entity Type:Individual
Prefix:
First Name:KYLEA
Middle Name:RAYE
Last Name:ROBERTS
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 1:5906 S MINTER RD
Mailing Address - Street 2:
Mailing Address - City:GRAIN VALLEY
Mailing Address - State:MO
Mailing Address - Zip Code:64029-9520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 NE SAM WALTON LN
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-8426
Practice Address - Country:US
Practice Address - Phone:816-525-2750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023027432183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist