Provider Demographics
NPI:1790911584
Name:EAGLES, KYLEE C (DO)
Entity Type:Individual
Prefix:
First Name:KYLEE
Middle Name:C
Last Name:EAGLES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KYLEE
Other - Middle Name:
Other - Last Name:MAYWALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:143 LONGWATER DR
Mailing Address - Street 2:
Mailing Address - City:NORWELL
Mailing Address - State:MA
Mailing Address - Zip Code:02061-1683
Mailing Address - Country:US
Mailing Address - Phone:781-878-5200
Mailing Address - Fax:
Practice Address - Street 1:143 LONGWATER DR
Practice Address - Street 2:
Practice Address - City:NORWELL
Practice Address - State:MA
Practice Address - Zip Code:02061-1683
Practice Address - Country:US
Practice Address - Phone:781-878-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA249666207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
042297845OtherTRICARE
1790911584OtherNEIGHBORHOOD HEALTH PLAN
MA1790911584Medicaid
92588601OtherNETWORK HEALTH PLAN
1790911584OtherFALLON