Provider Demographics
NPI:1063072965
Name:COYLE, KELLY K (LAC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:K
Last Name:COYLE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3809 S 2ND ST STE D100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-7059
Mailing Address - Country:US
Mailing Address - Phone:512-892-3366
Mailing Address - Fax:512-532-0810
Practice Address - Street 1:3809 S 2ND ST STE D100
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7059
Practice Address - Country:US
Practice Address - Phone:512-892-3366
Practice Address - Fax:512-532-0810
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-13
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01896171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty