Provider Demographics
NPI:1689264525
Name:DEVRIES, KYLEE NICOLE
Entity Type:Individual
Prefix:
First Name:KYLEE
Middle Name:NICOLE
Last Name:DEVRIES
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 1:47 FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07506-2317
Mailing Address - Country:US
Mailing Address - Phone:973-897-8835
Mailing Address - Fax:
Practice Address - Street 1:146 RECREATION BLDG
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PARK
Practice Address - State:PA
Practice Address - Zip Code:16802
Practice Address - Country:US
Practice Address - Phone:973-897-8835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-25
Last Update Date:2021-02-12
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