Provider Demographics
NPI:1811567837
Name:ROYER THYBULLE, KELLY PK
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:PK
Last Name:ROYER THYBULLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8020 HAMPTON BLVD APT 511
Mailing Address - Street 2:
Mailing Address - City:NORTH LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33068-5647
Mailing Address - Country:US
Mailing Address - Phone:786-458-3380
Mailing Address - Fax:
Practice Address - Street 1:8020 HAMPTON BLVD APT 511
Practice Address - Street 2:
Practice Address - City:NORTH LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33068-5647
Practice Address - Country:US
Practice Address - Phone:786-458-3380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care