Provider Demographics
NPI:1851671408
Name:KINNELL, KYLE ROBERT
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ROBERT
Last Name:KINNELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:SUITE M-401
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-349-7696
Mailing Address - Fax:269-488-8313
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:SUITE M-401
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-341-8855
Practice Address - Fax:269-341-8743
Is Sole Proprietor?:No
Enumeration Date:2011-08-26
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006110363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8650800300OtherBCBS