Provider Demographics
NPI:1851986467
Name:BERNTHISEL, KYLEE ANN (ATC,LAT)
Entity Type:Individual
Prefix:
First Name:KYLEE
Middle Name:ANN
Last Name:BERNTHISEL
Suffix:
Gender:F
Credentials:ATC,LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 PINEHURST DR
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34210-4501
Mailing Address - Country:US
Mailing Address - Phone:419-575-9328
Mailing Address - Fax:
Practice Address - Street 1:5840 26TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-3522
Practice Address - Country:US
Practice Address - Phone:941-752-5561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL4595207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine