Provider Demographics
NPI:1346862745
Name:THIEL, KYLE CREIGHTON (CRNP, ACNP)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:CREIGHTON
Last Name:THIEL
Suffix:
Gender:M
Credentials:CRNP, ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:570-326-8723
Mailing Address - Fax:570-326-8922
Practice Address - Street 1:1100 GRAMPIAN BLVD
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-1907
Practice Address - Country:US
Practice Address - Phone:570-326-8053
Practice Address - Fax:570-326-8638
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-08
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP021841363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner