Provider Demographics
NPI:1972340065
Name:GANNON, KYLE DOUGLAS
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:DOUGLAS
Last Name:GANNON
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 1:7123 WINDRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-8476
Mailing Address - Country:US
Mailing Address - Phone:317-600-7513
Mailing Address - Fax:
Practice Address - Street 1:7123 WINDRIDGE WAY
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-8476
Practice Address - Country:US
Practice Address - Phone:317-600-7513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program