Provider Demographics
NPI:1912540980
Name:ANDERSON, KYLE EDWARD (PMHNP-BC)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:EDWARD
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 NE 106TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-3934
Mailing Address - Country:US
Mailing Address - Phone:210-289-5953
Mailing Address - Fax:
Practice Address - Street 1:1410 NE 106TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-3934
Practice Address - Country:US
Practice Address - Phone:210-289-5953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202007455NP-PP363LP0808X
TXAP143637363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health