Healthcare Provider Details

I. General information

NPI: 1861166415
Provider Name (Legal Business Name): KYLE ANTHONY DELA CUESTA BSN, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2021
Last Update Date: 08/06/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1812 VERDUGO BLVD
GLENDALE CA
91208-1407
US

IV. Provider business mailing address

2173 YOSEMITE AVE
SIMI VALLEY CA
93063-3536
US

V. Phone/Fax

Practice location:
  • Phone: 818-952-2270
  • Fax:
Mailing address:
  • Phone: 805-428-0872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number95166664
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95166664
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: