Provider Demographics
NPI:1306684063
Name:ROBERTS, KYLEIGH GRACE
Entity type:Individual
Prefix:
First Name:KYLEIGH
Middle Name:GRACE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 MOSS VIEW ST APT E
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-5539
Mailing Address - Country:US
Mailing Address - Phone:615-598-8905
Mailing Address - Fax:
Practice Address - Street 1:130 HUNTER CT
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-7032
Practice Address - Country:US
Practice Address - Phone:270-904-5104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program