Provider Demographics
NPI:1720720097
Name:PETERSON, KYLIE BROOKE
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:BROOKE
Last Name:PETERSON
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 1:1 HERMANN PARK CT APT 254
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77021-2283
Mailing Address - Country:US
Mailing Address - Phone:469-777-1163
Mailing Address - Fax:
Practice Address - Street 1:6431 FANNIN ST # 5.170
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1501
Practice Address - Country:US
Practice Address - Phone:713-500-7160
Practice Address - Fax:713-500-0648
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-08
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program