Healthcare Provider Details

I. General information

NPI: 1730646456
Provider Name (Legal Business Name): KATHLYN MAE AUSTRIA DE LOS REYES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2019
Last Update Date: 03/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43322 GINGHAM AVE
LANCASTER CA
93535-4576
US

IV. Provider business mailing address

3221 VINELAND AVE APT 56
BALDWIN PARK CA
91706-5164
US

V. Phone/Fax

Practice location:
  • Phone: 661-874-4050
  • Fax: 888-977-1575
Mailing address:
  • Phone: 323-503-9927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95011307
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: