Provider Demographics
NPI:1447553938
Name:YACKLEY, KEVIN ALLEN (CRNA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:ALLEN
Last Name:YACKLEY
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 1:601 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:ONIDA
Mailing Address - State:SD
Mailing Address - Zip Code:57564-2133
Mailing Address - Country:US
Mailing Address - Phone:605-222-1912
Mailing Address - Fax:
Practice Address - Street 1:801 E SIOUX AVE
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501
Practice Address - Country:US
Practice Address - Phone:605-224-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-06
Last Update Date:2024-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR49835367500000X
SDCR001021367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered