Healthcare Provider Details

I. General information

NPI: 1285254623
Provider Name (Legal Business Name): PRESTON KYLE LONIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2020
Last Update Date: 09/27/2026
Certification Date: 09/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17777 VENTURA BLVD STE 200
ENCINO CA
91316-3748
US

IV. Provider business mailing address

21200 KITTRIDGE ST APT 2131
WOODLAND HILLS CA
91303-3043
US

V. Phone/Fax

Practice location:
  • Phone: 888-209-8874
  • Fax:
Mailing address:
  • Phone: 256-665-0559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number42658
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95026134
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-144879
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: