Provider Demographics
NPI:1821420126
Name:HODGES, KYLE LACY (APRN-FNP)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:LACY
Last Name:HODGES
Suffix:
Gender:M
Credentials:APRN-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLEY
Mailing Address - State:KS
Mailing Address - Zip Code:67748-1220
Mailing Address - Country:US
Mailing Address - Phone:785-672-3261
Mailing Address - Fax:785-672-8194
Practice Address - Street 1:212 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:OAKLEY
Practice Address - State:KS
Practice Address - Zip Code:67748-1220
Practice Address - Country:US
Practice Address - Phone:785-672-3261
Practice Address - Fax:785-672-8194
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-08
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS147228363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1679544811OtherMEDICARE PART A RHC
KS201106750AMedicaid
KS201106750DMedicaid