Provider Demographics
NPI:1093387730
Name:HIGGINSON, KYLE J (AG-ACNP-BC)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:J
Last Name:HIGGINSON
Suffix:
Gender:M
Credentials:AG-ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1288 N CEDAR BLVD UNIT 26
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84721-8621
Mailing Address - Country:US
Mailing Address - Phone:801-669-3534
Mailing Address - Fax:
Practice Address - Street 1:939 US-89 #1
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321
Practice Address - Country:US
Practice Address - Phone:801-669-3534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8886159-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner