Provider Demographics
NPI:1366236432
Name:RAVENELLE, KYLE
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:
Last Name:RAVENELLE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:ASHFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06278-1227
Mailing Address - Country:US
Mailing Address - Phone:860-942-3694
Mailing Address - Fax:
Practice Address - Street 1:78 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:ASHFORD
Practice Address - State:CT
Practice Address - Zip Code:06278-1227
Practice Address - Country:US
Practice Address - Phone:860-942-3694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-05
Last Update Date:2025-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3139146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic