Healthcare Provider Details

I. General information

NPI: 1053280685
Provider Name (Legal Business Name): CONNIE KUYKENDALL PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2025
Last Update Date: 11/03/2025
Certification Date: 11/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16008 JAMIE LN UNIT 7
FONTANA CA
92336-6166
US

IV. Provider business mailing address

16008 JAMIE LN UNIT 7
FONTANA CA
92336-6166
US

V. Phone/Fax

Practice location:
  • Phone: 909-800-7025
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95037472
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: