Provider Demographics
NPI:1952366577
Name:ST. JEAN, KYLE M (CRNA)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:M
Last Name:ST. JEAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 STAR MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-7734
Mailing Address - Country:US
Mailing Address - Phone:401-524-9492
Mailing Address - Fax:
Practice Address - Street 1:2601 LAKE DR STE 201
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6689
Practice Address - Country:US
Practice Address - Phone:919-783-4888
Practice Address - Fax:919-783-4887
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC308475163W00000X
NJ26NJ00175000363L00000X
NJNR11819500367500000X
NC5866367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD405760100Medicaid
MD360LJ873Medicare ID - Type Unspecified