Provider Demographics
NPI:1760774939
Name:JERSEY, KYLE EDWIN (RN)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:EDWIN
Last Name:JERSEY
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:KYLE
Other - Middle Name:EDWIN
Other - Last Name:JERSEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:1128 NE 20TH PLACE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32609
Mailing Address - Country:US
Mailing Address - Phone:352-234-6677
Mailing Address - Fax:
Practice Address - Street 1:1128 NE 20TH PLACE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609
Practice Address - Country:US
Practice Address - Phone:352-234-6677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-06
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9264326163WM1400X
FLMA60871225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No163WM1400XNursing Service ProvidersRegistered NurseNurse Massage Therapist (NMT)