Provider Demographics
NPI:1902503956
Name:UPP, KYLIE MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:MARIE
Last Name:UPP
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KYLIE
Other - Middle Name:MARIE
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:46-1039 EMEPELA WAY APT 15A
Mailing Address - Street 2:
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744-3984
Mailing Address - Country:US
Mailing Address - Phone:954-253-8957
Mailing Address - Fax:
Practice Address - Street 1:46-1039 EMEPELA WAY APT 15A
Practice Address - Street 2:
Practice Address - City:KANEOHE
Practice Address - State:HI
Practice Address - Zip Code:96744-3984
Practice Address - Country:US
Practice Address - Phone:954-253-8957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAPRN-3893363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIAPRN-3893OtherAPRN LICENSE NUMBER