Provider Demographics
NPI:1396596227
Name:AREVALO, KYLE CUSTODIO (MSN/ED, RN, AMB-BC)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:CUSTODIO
Last Name:AREVALO
Suffix:
Gender:M
Credentials:MSN/ED, RN, AMB-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:498 CHALAN PALOSYO
Mailing Address - Street 2:
Mailing Address - City:AGANA HEIGHTS
Mailing Address - State:GU
Mailing Address - Zip Code:96910-6427
Mailing Address - Country:US
Mailing Address - Phone:671-475-5794
Mailing Address - Fax:808-433-7756
Practice Address - Street 1:498 CHALAN PALOSYO
Practice Address - Street 2:
Practice Address - City:AGANA HEIGHTS
Practice Address - State:GU
Practice Address - Zip Code:96910-6427
Practice Address - Country:US
Practice Address - Phone:671-475-5794
Practice Address - Fax:808-433-7756
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GURX0802163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse