Provider Demographics
NPI:1942858048
Name:AVERY, KYLE BRANDON
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:BRANDON
Last Name:AVERY
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 1:223 PROSPECT AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5649
Mailing Address - Country:US
Mailing Address - Phone:231-883-5818
Mailing Address - Fax:
Practice Address - Street 1:223 PROSPECT AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5649
Practice Address - Country:US
Practice Address - Phone:231-883-5818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-01
Last Update Date:2019-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program