Provider Demographics
NPI:1457187528
Name:DISNEY, KYLE MITCHEL
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:MITCHEL
Last Name:DISNEY
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 1:5374 NW 117TH AVE
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-3214
Mailing Address - Country:US
Mailing Address - Phone:305-205-8751
Mailing Address - Fax:
Practice Address - Street 1:WEST BOCA MEDICAL CENTER
Practice Address - Street 2:21644 N STATE ROAD 7
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428
Practice Address - Country:US
Practice Address - Phone:561-488-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-13
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11035101363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care MedicineGroup - Multi-Specialty