Provider Demographics
NPI:1942984992
Name:BURTON, KYLIE NOEL
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:NOEL
Last Name:BURTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 W 600 N
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-8124
Mailing Address - Country:US
Mailing Address - Phone:765-244-7762
Mailing Address - Fax:
Practice Address - Street 1:1201 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1580
Practice Address - Country:US
Practice Address - Phone:765-244-7762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INF06230070363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily