Provider Demographics
NPI:1619691375
Name:WELLS, KYLA RASHELLE
Entity Type:Individual
Prefix:
First Name:KYLA
Middle Name:RASHELLE
Last Name:WELLS
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 1:843 MAYFIELD DR
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-6462
Mailing Address - Country:US
Mailing Address - Phone:330-531-0540
Mailing Address - Fax:
Practice Address - Street 1:100 N GREER BLVD
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:TX
Practice Address - Zip Code:75686-1409
Practice Address - Country:US
Practice Address - Phone:903-856-3686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14238183500000X
OH03337841183500000X
TX37868183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist