Provider Demographics
NPI:1154730661
Name:KOONS, KYLE S
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:S
Last Name:KOONS
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 1:1339 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-2505
Mailing Address - Country:US
Mailing Address - Phone:614-446-3622
Mailing Address - Fax:
Practice Address - Street 1:1339 N 6TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43201-2505
Practice Address - Country:US
Practice Address - Phone:614-446-3622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-08
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0105201Medicaid