Provider Demographics
NPI:1285723957
Name:HENNEBERRY, KYLE JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:JOSEPH
Last Name:HENNEBERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22100 BOTHELL EVERETT HWY
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98021-8431
Mailing Address - Country:US
Mailing Address - Phone:208-416-2932
Mailing Address - Fax:855-673-9190
Practice Address - Street 1:16040 NE 153RD ST
Practice Address - Street 2:
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072-8903
Practice Address - Country:US
Practice Address - Phone:208-416-2932
Practice Address - Fax:855-673-9190
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000473942085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3425956000OtherPASSPORT ADVANTAGE
VA1285723957Medicaid
KY7100029770OtherKY MEDICAID HEALTH CHOICES
VA1285723957Medicaid
KY998897Medicare PIN
VAMC10042Medicare PIN