Provider Demographics
NPI:1780302828
Name:BLACK, KYLIE RAEANN (PA-C)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:RAEANN
Last Name:BLACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KYLIE
Other - Middle Name:RAEANN
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 34703
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1703
Mailing Address - Country:US
Mailing Address - Phone:536-816-6262
Mailing Address - Fax:
Practice Address - Street 1:17707 W MAIN ST FL 1
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1967
Practice Address - Country:US
Practice Address - Phone:360-282-3885
Practice Address - Fax:360-512-2026
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61482872363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant