Provider Demographics
NPI:1568974996
Name:BOISSELLE, KYLE MATTHEW
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:MATTHEW
Last Name:BOISSELLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 JEWEL ST
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03581-1211
Mailing Address - Country:US
Mailing Address - Phone:603-852-2634
Mailing Address - Fax:
Practice Address - Street 1:18 JEWEL ST
Practice Address - Street 2:
Practice Address - City:GORHAM
Practice Address - State:NH
Practice Address - Zip Code:03581-1211
Practice Address - Country:US
Practice Address - Phone:603-852-2634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer