Healthcare Provider Details

I. General information

NPI: 1346645595
Provider Name (Legal Business Name): KAITLIN REISS ANDERSON DNP, CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAITLIN ELIZABETH REISS RN

II. Dates (important events)

Enumeration Date: 10/30/2014
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 MORRO RD
ATASCADERO CA
93422-4435
US

IV. Provider business mailing address

7700 MORRO RD
ATASCADERO CA
93422-4435
US

V. Phone/Fax

Practice location:
  • Phone: 805-466-6622
  • Fax: 805-461-0361
Mailing address:
  • Phone: 805-466-6622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number21374
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95012201
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number225342
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: