Provider Demographics
NPI:1760709679
Name:KYLE TKACHUK, LAUREN ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:ANN
Last Name:KYLE TKACHUK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LAUREN
Other - Middle Name:ANN
Other - Last Name:KYLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 741331
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1331
Mailing Address - Country:US
Mailing Address - Phone:913-469-0503
Mailing Address - Fax:
Practice Address - Street 1:7840 W 165TH ST STE 260
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66223-3020
Practice Address - Country:US
Practice Address - Phone:913-871-8221
Practice Address - Fax:913-273-0337
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-02
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KS04-36968207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program