Provider Demographics
NPI:1629672555
Name:MCDONALD, KYLIE (NP-C)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 MARTIN SPRINGS DR STE 250
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-2980
Mailing Address - Country:US
Mailing Address - Phone:573-458-6363
Mailing Address - Fax:
Practice Address - Street 1:1605 MARTIN SPRINGS DR STE 250
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2980
Practice Address - Country:US
Practice Address - Phone:573-458-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-22
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020021050363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily