Provider Demographics
NPI:1689940934
Name:MERRITT, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:MERRITT
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 1:1818 HARDEN BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-1812
Mailing Address - Country:US
Mailing Address - Phone:239-278-1155
Mailing Address - Fax:239-278-1159
Practice Address - Street 1:1818 HARDEN BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-1812
Practice Address - Country:US
Practice Address - Phone:239-278-1155
Practice Address - Fax:239-278-1159
Is Sole Proprietor?:No
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106424363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical