# KIN MED, PA

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1861994204
- **Authorized official:** DR. LYETTE ROSE BOUCHER (PRESIDENT)
- **Authorized official phone:** (239) 948-1222

## Contact information

- **Practice address:** 19910 S TAMIAMI TRAIL STE C, ESTERO, FL 33928
- **Practice address phone:** (239) 948-1222
- **Practice address fax:** (239) 948-1221
- **Mailing address:** 19910 S. TAMIAMI TRAIL STE C, ESTERO, FL 33928
- **Mailing address phone:** (239) 948-1222
- **Mailing address fax:** (239) 948-1221

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208D00000X | General Practice Physician | CH11148 | — | — |
| 208D00000X | General Practice Physician | CH11313 | FL | Yes |
| 363A00000X | Physician Assistant | P.A.9104809 | FL | — |

## Other

- **Enumeration date:** 03/01/2018
- **Last updated:** 03/01/2018