Provider Demographics
NPI:1053657015
Name:KYLE, CICELY JEVON (PA-C)
Entity type:Individual
Prefix:
First Name:CICELY
Middle Name:JEVON
Last Name:KYLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9400 UNIVERSITY PKWY
Mailing Address - Street 2:SUITE 101B
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-5752
Mailing Address - Country:US
Mailing Address - Phone:850-208-6130
Mailing Address - Fax:
Practice Address - Street 1:9400 UNIVERSITY PKWY
Practice Address - Street 2:SUITE 101B
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-5752
Practice Address - Country:US
Practice Address - Phone:850-208-6130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-19
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.869363A00000X
FLPA9109666363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant