Provider Demographics
NPI:1679344055
Name:KINCAID, KYLEE (MSAT, LAT, ATC)
Entity type:Individual
Prefix:
First Name:KYLEE
Middle Name:
Last Name:KINCAID
Suffix:
Gender:F
Credentials:MSAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:863 E VILLAGE RD
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404-3889
Mailing Address - Country:US
Mailing Address - Phone:801-458-0977
Mailing Address - Fax:
Practice Address - Street 1:863 E VILLAGE RD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404-3889
Practice Address - Country:US
Practice Address - Phone:801-458-0977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID11612752255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer