Provider Demographics
NPI:1710910013
Name:KOSTYUN, KYLE JEFFREY (ATC)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:JEFFREY
Last Name:KOSTYUN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 HOLLISTER DR
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-2934
Mailing Address - Country:US
Mailing Address - Phone:813-416-5546
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:399 FARMINGTON AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1936
Practice Address - Country:US
Practice Address - Phone:860-284-0235
Practice Address - Fax:860-284-0221
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0106020212255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL995586OtherNATA MEMBER NUMBER