Provider Demographics
NPI:1407014723
Name:HUTSELL, KYLIE MICHELLE (P A)
Entity Type:Individual
Prefix:MRS
First Name:KYLIE
Middle Name:MICHELLE
Last Name:HUTSELL
Suffix:
Gender:F
Credentials:P A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11912 ELM ST STE 26
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-4363
Mailing Address - Country:US
Mailing Address - Phone:402-330-4770
Mailing Address - Fax:402-330-2711
Practice Address - Street 1:11912 ELM ST STE 26
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-4363
Practice Address - Country:US
Practice Address - Phone:402-330-4770
Practice Address - Fax:402-330-2711
Is Sole Proprietor?:No
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2291363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical