Provider Demographics
NPI:1255707758
Name:STEVENS, KYLE (CRNA)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:STEVENS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:829 ELLIS AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19073-3904
Mailing Address - Country:US
Mailing Address - Phone:570-954-8117
Mailing Address - Fax:
Practice Address - Street 1:1 COOPER PLZ STE 294B
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-1461
Practice Address - Country:US
Practice Address - Phone:856-342-2425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN566423367500000X
NJ26NJ01187800367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered