Provider Demographics
NPI:1043053143
Name:COYLE, KIMBERLY SUE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:COYLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:SUE
Other - Last Name:KEAHEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 E WILLIAM J BRYAN PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77803-5371
Mailing Address - Country:US
Mailing Address - Phone:979-361-5780
Mailing Address - Fax:
Practice Address - Street 1:300 E WILLIAM J BRYAN PKWY STE 200
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77803-5371
Practice Address - Country:US
Practice Address - Phone:979-361-5780
Practice Address - Fax:979-361-5781
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1166649363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily