Provider Demographics
NPI:1417679762
Name:OLEARY, KYLE JAMES (ARNP)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:JAMES
Last Name:OLEARY
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1442 NE 26TH ST
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33305-1322
Mailing Address - Country:US
Mailing Address - Phone:954-391-7160
Mailing Address - Fax:954-393-0811
Practice Address - Street 1:1442 NE26TH ST
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33305-3330
Practice Address - Country:US
Practice Address - Phone:954-391-7160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-14
Last Update Date:2024-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11021418363LF0000X, 363L00000X, 363LP0200X, 363LP2300X, 363LX0106X, 261QM1300X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational HealthGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1003647587OtherNPPES
FL1003647587Medicaid