Provider Demographics
NPI:1093340515
Name:FARWELL, KYLINE NICOLE (PA)
Entity type:Individual
Prefix:
First Name:KYLINE
Middle Name:NICOLE
Last Name:FARWELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KYLIE
Other - Middle Name:NICOLE
Other - Last Name:FARWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:6015 N INTERSTATE AVE APT 441
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-4792
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5050 NE HOYT ST STE 626
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2956
Practice Address - Country:US
Practice Address - Phone:503-917-3950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-04
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
ORPA201995363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant