Provider Demographics
NPI:1588480685
Name:FARIS, KYLE RYAN (ACNPC-AG)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:RYAN
Last Name:FARIS
Suffix:
Gender:M
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10210 NE 189TH ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-3836
Mailing Address - Country:US
Mailing Address - Phone:760-217-8584
Mailing Address - Fax:
Practice Address - Street 1:1001 MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-2035
Practice Address - Country:US
Practice Address - Phone:309-672-5682
Practice Address - Fax:309-672-3147
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-23
Last Update Date:2025-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209032698363LG0600X
WARN60857175163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology