Provider Demographics
NPI:1346825189
Name:THAYER, KYLELYNE DEEANNE
Entity Type:Individual
Prefix:
First Name:KYLELYNE
Middle Name:DEEANNE
Last Name:THAYER
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 1:3865 YORKLAND DR NW APT 7
Mailing Address - Street 2:
Mailing Address - City:COMSTOCK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:49321-8138
Mailing Address - Country:US
Mailing Address - Phone:616-490-8961
Mailing Address - Fax:
Practice Address - Street 1:4542 KENOWA AVE SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-9523
Practice Address - Country:US
Practice Address - Phone:616-667-9713
Practice Address - Fax:616-667-9715
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303014544183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician