Provider Demographics
NPI:1538407382
Name:KIEL, BRYCE (CRNA)
Entity type:Individual
Prefix:
First Name:BRYCE
Middle Name:
Last Name:KIEL
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 1:604 SOMERSET DR
Mailing Address - Street 2:
Mailing Address - City:PONTOON BEACH
Mailing Address - State:IL
Mailing Address - Zip Code:62040-6923
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6800 STATE ROUTE 162
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8500
Practice Address - Country:US
Practice Address - Phone:217-288-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010185367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered