Provider Demographics
NPI:1285067868
Name:RISENDAL, KYLIE PERKINS (PA-C)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:PERKINS
Last Name:RISENDAL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KYLIE
Other - Middle Name:ELISE
Other - Last Name:PERKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 388
Mailing Address - Street 2:
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939-0388
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:70 MEDICAL CENTER CIR STE 103
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2273
Practice Address - Country:US
Practice Address - Phone:540-245-7400
Practice Address - Fax:540-245-7401
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2040363A00000X
VA0110008477363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant