Provider Demographics
NPI:1700368081
Name:STREET, KYLIE NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:NICOLE
Last Name:STREET
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14210 SPECKING AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-4167
Mailing Address - Country:US
Mailing Address - Phone:907-240-1213
Mailing Address - Fax:
Practice Address - Street 1:3831 PIPER ST STE S220
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:907-563-3145
Practice Address - Fax:907-561-3967
Is Sole Proprietor?:No
Enumeration Date:2018-09-03
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program