Provider Demographics
NPI:1427882943
Name:ALEXANDER, KYLE LEE
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:LEE
Last Name:ALEXANDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 YEW CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-7806
Mailing Address - Country:US
Mailing Address - Phone:309-310-1749
Mailing Address - Fax:
Practice Address - Street 1:1505 EASTLAND DR STE 1100
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7905
Practice Address - Country:US
Practice Address - Phone:309-663-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.030259363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily