Basic Information
| Provider Information | |||||||||
| NPI: | 1093195398 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORRELL | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | NATHANIEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3775 TIMOTHY LN | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180206962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4846950720 | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 N CLYDE MORRIS BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321142765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862544165 | ||||||||
| FaxNumber: | 3862544339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2015 | ||||||||
| LastUpdateDate: | 06/02/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 21903 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.